LIBRARY OF CONGRESS, 

®]^^.-A^^@uiU|rig^f0 

Slielf....S.&3 

) S^2j 

UNITED STATES OF AMERICA. 



TREATISE ON THE 



DISEASES OF WOMEIT 



FOR THE USE OF 
STUDENTS AND PRACTITIONERS 



BY 

ALEXANDEK J. C. SKE^^E, M. D. 

PROFESSOR OF GYNECOLOGY IN THE LONG ISLAND COLLEGE HOSPITAL, BROOKLYN, NEW YORK 

FORMERLY PROFESSOR OF GYNECOLOGY IN THE NEW YORK POST-GRADUATE MEDICAL SCHOOL 

GYNECOLOGIST TO THE LONG ISLAND COLLEGE HOSPITAL 

PRESIDENT OF THE AMERICAN GYNECOLOGICAL SOCIETY, 1887 

CORRESPONDING MEMBER OF THE BRITISH, BOSTON, AND DETROIT GYNECOLOGICAL SOCIETIES 

OF THE ROYAL SOCIETY OF MEDICAL AND NATURAL SCIENCES OF BRUSSELS 

AND OF THE LEIPZIG OBSTETRICAL SOCIETY 

FELLOW OF THE NEW YORK ACADEMY OF MEDICINE 

EX-PRESIDENT OF THE MEDICAL SOCIETY OF THE COUNTY OF KINGS 

EX-PRESIDENT OF THE NEW YORK OBSTETRICAL SOCIETY 



\ 



SECOND EDITION, REVISED AND ENLARGED 
WITH 251 ENGRAVINGS AND 9 CHROMO-LITHOGRAPHS 



NEW YORK 
D. APPLE TON AND COMPANY 

1892 



APR 23 18S2 y 

76 6^7^ 



CoPYKiGHT, 1888, 1892, 
By D. APPLETON AND COMPANY. 



TO 
THOMAS KEITH, M. D., LL. D., F. R. C. S. E., 

THIS WORK IS DEDICATED 

AS A TRIBUTE TO HIS ACHIEVEMENTS IN SURGERY, 

HIS JUSTICE AND COURTESY TO THE MEDICAL PROFESSION OF AMERICA 

AND AS AN ACKNOWLEDGMENT OF HIS KINDNESS TO THE AUTHOR. 



/ 



PEEFACE TO THE SECOND EDITIOI^J^. 



The demand for a second edition of this work, and the fact that 
it is used as a text book in many of the leading medical schools, are 
very gratifying to the author, who takes this opportunity to thank 
the members of the medical profession for this evidence of their 
approbation. 

Every effort has been made to improve this edition by a thor- 
ough revision and the addition of much new material. 

I^ew chapters have been added on ectopic gestation^ diseases 
and injuries of the ureters, vesical hernia and its surgical treatment, 
and the latest views of the author have been given in the discussion 
of laparotomy, ovaritis, and injuries of the cervix uteri and pel- 
vic floor. 

The publishers have, at great expense, produced a large number 
of new and handsome illustrations, and in every respect have made 
the work a perfect sample of their art. 

The Author. 

April 15, 1892. 



PREFACE 



This book was written for the purpose of bringing together 
the fullj matured and essential facts in the science and art of gyne- 
cology, so arranged as to meet the requirements of the student of 
medicine, and be convenient to the practitioner for reference. In 
the plan adopted, the diseases peculiar to women are, as far as 
possible, divided into three classes. The iirst class comprises those 
which occur between birth and puberty ; the second, those between 
puberty and the menopause ; and the third, those which come after 
the menopause. 

Each subject is briefly described, and histories of cases, typical 
and complicated, are given as illustrative of the disease or injury 
under consideration, together with the author's method of treat- 
ment. The number of illustrative cases given depends upon the 
practical importance of the subject and the ability to make it more 
plain by the use of illustrations. 

In carrying out this plan, the history of gynecology and the 
discussion of all unsettled questions have been omitted, as being at 
variance with the plan adopted. 

Credit has been given as far as possible to those who have 
made original discoveries, but a vast number of original workers 
have been passed unnoticed for want of time and space even to 
name them. 

To the medical student, history has no value until he has 
mastered the rudiments of the science and the art, and the prac- 
titioner can find in the works of reference all the historical facts 
which he may seek. 



yi PREFACE. 

The author lias ventured to give his own views and methods 
pertaining to practical matters, believing that while thej may differ 
to some extent from the general literature of the day, they will 
be found reliable in practice and may be of interest to the spe- 
ciahst. 

Marginal references have not been made, because all selections 
from the literature that have been incorporated in this work are 
those already well established and familiar to the gynecologist, 
and foot-notes only embarrass the reader who is seeking for the 
facts alone. 

Acknowledgments are due to my associates — Dr. J. H. Ray- 
mond, who has rendered valuable aid in the preparation of the 
work, and Dr. ~R. L. Dickinson, who has made the drawings for 
the original illustrations. 

The Author. 



TABLE OF CONTENTS. 



CHAPTER 

I.- 

II.- 

III.- 



IV.- 

V.- 

VI.- 

VII.- 

VIII.- 

IX.- 

X.- 

XI.- 

XII.- 

XIII.- 

XIV.- 

XV.- 

XVI. 

XVII.- 

XVIIL- 

XIX. 

XX.- 

XXI.- 

XXII. 

XXIII.- 

XXIV.- 

XXV.- 

XXVI.- 

XXVII.- 

XXVIII.- 

XXIX.- 

XXX.- 

XXXI.- 

XXXII.- 



-Methods of Observation ..„.,. 

-Development of the Sexual Organs . . . . 

-Arrest of Development and Entire Absence of Functional 
Activity — Arrest of Development ai^d Growth in the 
Later Stages of Evolution, and Consequent Imperfection 
OF Function ..... 

-Flexions op the Uterus .... 

-Diseases of the External Organs of Generation 

-Diseases of the Vagina .... 

-Injuries to the Pelvic Floor from Parturition and 
Causes ...... 

-Fistula in Ano and Coccyodynia 

-Imflammatory Affections of the Uterus 

-Corporeal Endometritis .... 

-Subinvolution ..... 

-Sclerosis of the Uterus .... 

-Membranous Dysmenorrhcea 

-Lacerations of the Cervix Uteri due to Parturition 

-Cicatrices of the Cervix Uteri and Vagina . 

-Inversion of the Uterus .... 

-Dislocations of the Uterus 

-Retroversion of the Uterus 

-Abuse of Pessaries . . . 

-Hypertrophy of the Cervix Uteri 

-Fibroma of the Uterus . . . . ■ 

-Malignant Disease of the Uterus 

-The Menopause ..... 

-Diseases of the Ovaries .... 

-Diseases of the Ovaries (continued) 

-Neoplasms of the Ovaries. 

-Cystic Tumors of the Ovaries — Symptojiatology and Phys- 
ical Signs ...... 

-Ovariotomy ...... 

-Illustrative Cases of Ovarian Neoplasms 

-Diseases of the Fallopian Tubes 

-Pelvic Cellulitis ..... 

-Pelvic Peritonitis . . . c . 



PAGE 

1 

22 



30 
54 
76 
99 

112 
162 
171 
202 
214 
220 
229 
242 
259 
266 
279 
304 
334 
343 
348 
398 
422 
438 
454 
473 

488 
509 
530 
547 
555 
579 



viii TABLE OF CONTENTS. 

CHAPTER PAGE 

XXXIir.— Pelvic Hematocele. . . . . . .596 

XXXIV. — Diseases of the Urinary Organs — Anatomy and Develop- 
ment OF the Bladder and Urethra .... 609 

XXXV. — Malformations of the Bladder and Urethra . , . 622 

XXXVI. — Function of the Bladder ...... 647 

XXXVII. — Functional Diseases of the Bladder . . . . 653 

XXXVIII. — Functional Diseases of the Bladder (continued) . , 674 

XXXIX. — Methods of Exploration of the Bladder and Urethra . 694 

XL. — Organic Diseases of the Bladder .... 703 

XLI. — Organic Diseases of the Bladder (continued) — Treatment of 
Cystitis — Croupous and Diphtheritic Cystitis — Cystitis 

WITH Epidermoid Concretions ..... 736 

XLIL — Non-Inflammatory Diseases of the Bladder — Dislocation 

OF the Bladder . . . . . . . 760 

XLIII. — Foreign Bodies in the Bladder ..... 777 

XLIV. — Rupture OF the Bladder ...... 793 

XLV. — Neoplasms, Hyperplasia, and Atrophy of the Bladder . 804 

XLVI. — Diseases of the Urethra and Urethral Glands . . 818 

XLVII. — Dilatation, Dislocation, and Prolapsus of the Urethra . 849 
XLVIII. — Stricture, Foreign Bodies, and Incomplete Fistula of the 

Urethra ........ 868 

XLIX. — Diseases of the Glands of the Female Urethra . . 879 

L. — Vesical and Urethral Fistula ..... 892 

LI. — Diseases and Injuries of the Ureters .... 909 

LII. — Ectopic Gestation ....... 920 

LIII. — Gynecology as related to Insanity in Women . . . 930 



INDEX TO ILLUSTEATIOl^S. 



FIG. 










PAGE 


1. Examining table . . . . . . . . 8 


2. Bimanual examination . 




. 9 


3. Sims's speculum 




. 


. 11 


4. Cusco's bivalve speculum 


. 






11 


5. Sims's position, seen from above 


. 






12 


6. Nurse holding Sims's speculum 








12 


7. The movements of the speculum— first movement . 






13 


8. " " — second movement 






13 


9. " " —third movement . 






14 


10. Hunter's depressor 






14 


11. Sims's probe 










15 


12. Whalebone sound 










15 


13. Jenks's sound . • 










15 


14. Skene's curette . 










16 


15. Hanks's dilator . 










17 


16. Goodell's dilator 










17 


17. Sponge tents 










18 


18. Tupelo tents 










18 


18a. Ether inhaler . 










21 


19. Mliller's ducts . 










22 


20. Coalescence of ducts 










22 


21. Disappearance of septum 








22 


22. Appearance of fundus and cervix 








22 


23. Infantile uterus (Winckel) 








23 


24. Palma plicata . 








23 


25. Infantile uterus, antero-posterior section, scant invaginatioi 






23 


26. Virgin uterus (Sappey) — anterior view 






24 


27. " " —median section 






24 


28. " " —transverse section . 






24 


29. Double uterus and vagina (Eisenmann) 






25 


30. Uterus, unicornis (Pole) ..... 






26 


31. Uterus bicornis unicollis (Winckel) . 








26 


32. Uterus bifundalis unicollis (Courty) . 








27 


33. Uterus duplex (Cruveilhier) 








27 


34. Double uterus . 








•39 


34a. Anteflexion of cervix— first variety 








57 


35. Anteflexion of body of uterus— second variety 






58 


36. Anteflexion of body and cervix — third variety 






58 


37. Operation for imperfect invagination ; the incision . 






66 


38. 


"' 


sutures in position 






66 



INDEX TO ILLUSTEATIONS. 



FIG. 

39. Elliott's uterine adjuster . 

44. Stem pessary of Thomas .... 

45. Extreme anteflexion 

46. Skene's hysterotome ..... 

47. External genitals of a woman who has borne children 
'48. The superficial veins of the perinaeum (Savage) 

49. External genitals of a virgin .... 

50. Cribriform hymen ..... 

51. Annular hymen ..... 

52. Fimbriate hymen ..... 

53. Rectum continuous with allantois (bladder) and duct of Miiller 

(Schroeder) . . . . ' . 

54. The depression has extended inward (Schroeder) 

55. The cloaca is dividing (Schroeder) 

56. The perineal body is completely formed (Schroeder) 

57. The upper part has contracted (Schroeder) 

58. Spurious hermaphroditism (Simpson) . 

59. Length of vaginal walls . . . . 

60. Triangular shape of the perineal body 

61. Sims's vaginal dilator . . . . 

62. The levator ani (after Luschka) 

63. The muscles of the pelvic floor (after Hart and Savage) 

64. Diagrammatic sagittal section of the female pelvis . 

65. Complete laceration of the perinaeum . 

66. Sagging of the pelvic floor .... 

67. Diagram of the sweep of the suture . . . 
68-69. Sutures properly and improperly introduced 

70. Peaslee's needle ..... 

71. Skene's tissue forceps ..... 

72. Emmet's curved scissors .... 

73. Emmet's scissors ..... 

74. First step of perineorrhaphy, denudation begun 

75. Second step, continuing the strip . . ; 

76. Vivifying complete ....." 

77. Skene's needle-forceps ..... 

78. Stitch in place ...... 

79. The stitches in place ..... 

80. Laceration with rectocele .... 

81. Perineal body restored (profile view) . 

82. Scissors for removing sutures . . . o 

83. Complete laceration of perinaeum 

84. do. operation ; denudation complete 

85. do. " rectal sutures 

86. do. " the remaining sutures placed . 

87. Haemorrhoid clamp ..... 

88. Hard-rubber rectal tube . ^^Ipii. . 

89. The operation for fistula in ano ... 

90. Mold of uterine cavity in the virgin (Guyon) . 

91. '' " " " multipara (Guyon) 

92. Section of mucous membrane of uterus 

93. " through corpus uteri of an infant 

94. " " " " of a woman aged eighty-three 



vagina) 



Plate I 

Plate I 

Plate II 

Plate II 



INDEX TO ILLUSTRATIONS. 



XI 



FIG. 

95. One of the median columns in the cervical canal (Coiirty) . 

96. Section through the mucous membrane of cervix showing cystic 

eration 

97. Elongation of the cervix (Winckel) . 

98. Hypertrophy of the body of uterus (Winckel) 

99. General enlargement of uterus (Winckel) 

100. Skene's instillation tube 

101. Sims's curette .... 

102. The two sides of a half membrane from a multipar 

103. Half a membrane from a virgin 

104. A cast from a virgin . 
104a. Fragments of membrane in the condition in which they ar 

expelled .... 
104&, 104c. A cast which might be taken for a product of conception 

105. Bilateral laceration ; unequal division of the cervix 

106. Bilateral laceration, with thickening of the everted lips 

107. Extensive multiple laceration 

108. Multiple incomplete laceration 

109. Incomplete bilateral laceration 

110. " " " in section 

111. Crescentic laceration 

112. Skene's hawk-bill scissors 

113. Denudation of cervix . 

114. Skene's triangular needles 

115. Counter-pressure instrument . 

116. Sutures in place 

117. Sutures tied .... 

118. Removal of creseentic-shaped piece (seen in section) 
119-120. Method of bringing the sides of the section together 
121-122. Another method of closing the gap 

123. Partial inversion (Thomas) . 

124. Complete inversion (Thomas) . 

125. Polypus simulating partial inversion (Thomas) 

126. Polypus simulating complete inversion (Thomas) 

127. Byrne's method of reduction of inversion 

128. Cup pessary to exercise gradual pressure (Thomas) 

129. Replacement of uterus by dilatation through abdomen (Thomas) 

130. Section of pelvis, showing its inclination and the axis of the inlet 

131. The normal range of the uterine axis (Van der Warker) . 

132. Diagram of the uterine ligaments .... 

133. Section of pelvis, with the slings of the uterus 

134. Diagram of the uterus slung between the broad ligaments 

135. The normal inclination of the pelvis and the transmission of for 

above ....... 

136. The three degrees of prolapsus 

137. Prolapsus uteri with cystocele . 

138. The shallow pelvis with lessened inclination of brim 

139. Increased inclination of inlet 

140. Uterus replaced, with pessary in position 

141. Stem pessary, modification of Cutter's 

142. The three degrees of retroversion 

143. Retroversion of the second degree 



PAGE 

175 



degen- 



often 



Plate in 



Plate 111 
Plate III 



xu 



INDEX TO ILLUSTRATIONS. 



FIG. 

144. Retroversion with imperfect invagination of cervix 

145. Apparent imperfect invagination 

146. The same uterus with its lips drawn back into place 

147. The three steps in replacing the retroverted uterus by means of sponge- 

holders ....... 

148. Albert Smith pessary ...... 

149. Method of measuring the length of the pessary 

150. Diagram of pessary in situ on looking through Sims's speculum 

151. Slight invagination of cervix posteriorly with suitable pessary 

152. Decided invagination of cervix posteriorly fitted with a suitable pessary 

153. What the pessary does not do . . . 

154. How the pessary acts ..... 

155. Second step; the uterus falls into the pessary 

156. The knee-chest position .... 

157. Fibroid on posterior wall of uterus simulating retroflexion 

158. Prolapsed and adherent ovary simulating retroversion 

159. Extreme retroflexion (Barnes) 

160. Uterus with defective walls ; the supra-vaginal portion of the cervix is 

elongated (after Winckel) .... 

161. Stem of pessary ulcerating through cervix . 

162. Stem cutting through body of uterus 

163. High rectocele due to improper pessary 

164. Displacement caused by a badly adjusted pessary . 

165. Hypertrophy of the cervix .... 

166. The first step ; splitting the cervix . 

167. The double fiaps of the amputation . 

168. Diagram of the pieces removed 

169. The sutures in place ..... 

170. The sutures tied ..... 
171-172. Interstitial fibromata (Winckel) . 

173. Subperitoneal and submucous fibromata (Winckel) . 

174. Pedunculated submucous fibroid (Simpson) . 
175-176. Enlargement due to subinvolution compared with that from growth 

of a fibroma (after Winckel) 

177. Ecraseur ...... 

178. Wall of uterus caught, in ecraseur-wire and removed 

179. Electrical action hi a single cell 

180. Law cell 

181. Milliamperemeter ..... 

182. Rheostat 

183. Uterine electrode ..... 

184. Cancer of both lips (Winckel) 

185. The fundus uteri and ovaries seen through the pelvic brim (His) 

186. The ovary and its ligaments (Henle) . 

187. The ovarian, uterine, and vaginal arteries (Hyrtl) . 

188. Section of the ovary of a bitch (Waldeyer) . 

189. Ovary displaced and bound down by adhesions 

190. Left ovary, one large cyst (Farre) 

191. Compound and proliferating cyst (Farre) 

192. Multilocular cyst (Hooper) . . 

193. Papillary cystoma of ovary (Winckel) 

194. Dermoid cyst of ovary (Winckel) 



INDEX TO ILLUSTRATIONS. 



xiu 



195. Fibroma affecting both ovaries (Winckel) 

196, 197. Area of dullness in ovarian tumor and in ascites (Barnes) 



198. 
199. 
200. 
201. 
202. 
208. 



Cautery clamp . 

Keith's short compression-forceps 

Keith's long compression-forceps 

Keith's needle . 

Keith's ligature-forceps 

Keith's modification of Spencer Wells's clamp 

204. Position of operator, assistants, and accessories in ovariotomy 

205. Diagrammatic transverse section of the pelvis (Luschka) . 

206. Pelvic abscess opening obliquely downward . 

207. Pelvic abscess opening obliquely upward 

208. The pelvic peritonaeum (Hodge) .... 

209. The reflections and pouches of the pelvic peritonaeum (Hodge) 

210. Retroverted uterus bound back by peritonitic adhesions (Winckel) 

211. Subperitoneal pelvic hsematocele 

212. Intra-peritoneal pelvic haematocele . 

213. Diagram of the bladder to show corpus and fundus 

214. Base and neck of the bladder (Savage) 

215. Urethra laid opeii with probes distending the glands (posterior wall di- 

vided) 

216. Urethra laid open with probes in Skene's glands (anterior wall divided) 

217. Transverse section of urethra with gland on either side 

218. Longitudinal section of urethral glands 

219. The meatus everted showing the mouths of the glands 

220. The relations of the ureters (Garrigues) 

221. Extroversion of the bladder ..... 

222. Linear cicatrix ...... 

223. Bladder covered by deep flaps .... 

224. Diagram of the result of the operation . . . 
225-227. Skene's endoscope ..... 
227a. Principal of the Nitze-Leiter cystoscope . 
227b. " u u "... 
227c. Leiter cystoscope ...... 

228. Skene's bivalve urethral speculum .... 

229. Fountain-syringe for washing bladder 

230. Skene's instillation-tube ..... 

231. Skene's urinal cup-pessary ..... 

232. Holt's catheter, with its modifications 

233. Skene's modification of Goodman's self-retaining catheter . 

234. Retroversion of the gravid uterus (Schatz) . 

235. Skene's pessary for prolapsus of the bladder 

236. Pessary holding up the bladder .... 

237. Modification of the retroversion pessary, used in prolapsus of the bladder 

238. Forward transposition of the uterus . 

239. Retrocession of the uterus 

240. Skene's reflux catheter 

241. Skene's fissure probe and knife 

242. Skene's urethral speculum 

243. Skene's modification of Folsom's nasal speculum 

244. Allen's polypus forceps 

245. Blake's polypus snare .... 



PAGE 

479 
495 
513 
519* 
519* 
520 
520 
520 
521 
555 
557 
557 
579 
580 
582 
596 
597 
610 
612 



XIV 



INDEX TO ILLUSTKATIONS. 



FIG. 

246. Dilatation of middle third of the urethra 

247. Skene's button-hole scissors . 

248. Dislocation of upper third of urethra 

249. Complete dislocation with dilatation 
249a. Operation for prolapse and dilatation 
249&. Growths at the mouths of the glands 

250. Sims's tenaculum .... 

251. Operation for vesico- vaginal fistula ; paring the edges 

252. Sims's sponge-holder .... 

253. Emmet's needles ..... 

254. Curved track of the needle .... 

255. Operation for vesico- vaginal fistula ; the sutures in place 

256. Two sutures tied . . . . 

257. Kelly's ureteral catheter .... 



Plate IV 
Plate IV 



PAGE 

852 
860 
861 

862 



897 
898 
898 
899 
899 
900 
900 
910 



Plate I, Fig. 83. Complete laceration of perinaeum. . 

I, Fig. 84. do. operation ; denudation. 

II, Fig. 85. do. " rectal sutures. 

II, Fig. 86. do. " remaining sutures. 

Ill, Fig. 113. Bilateral laceration of cervix ; denudation. 

Ill, Fig. 116. do. sutures in place. 

III, Fig. 117. do. sutures tied. 

IV, Fig. 249a. Prolapse of urethra; operation. 

IV, Fig. 2496. Growths at mouths of Skene's glands. 



Note. — All illustrations not credited are from original drawings by Robert L. 
Dickinson, M. D., excepting instruments, and Figs. 92, 93, 94, 96, 217, and 218, by 
J. M. Van Cott, Jr., M. D., and Figs. 215 and 216, by A. H. P. Leuf, M. D. 



DISEASES OF WOMEN, 



CHAPTER I. 

METHODS OF OBSERVATION. 

A THOROUGH familiarity with the means and methods of investi- 
gation is the first requisite in acquiring knowledge. The art of ob- 
servation, which is simply the systematic use of the mental and phys- 
ical faculties to obtain facts, should be made an essential part of the 
preliminary training of every student of medicine. From this point 
of view, the subject which we have to consider resolves itself into 
two divisions: first, the ways and means of investigation; and, sec- 
ond, the objects to be studied. 

Before approaching the study of gynecology, it is taken for 
granted that much experience and practice have been attained by 
the student in the art of investigation. The experience of every- 
day life, from infancy onward, and the ordinary school education 
obtained before beginning the study of medicine, tend to develop and 
cultivate the perceptive faculties. Still, the physician and surgeon 
require special training in the art of observation. To accurately note 
the structure, form, color, general proportions, and expressions of 
the human body in health, is the first lesson which every student of 
medicine should learn. This ^is the most important step toward the 
attainment of a practical knowledge regarding the functions of the 
human body, and its deformities, diseases, and injuries. The cor- 
rect, rapid, and thorough observer has from the outset great advan- 
tages. Important and necessary as this branch of education is, it is 
almost wholly neglected in schools and colleges. The chief occupa- 
tion of teachers appears to be to impart knowledge already in exist- 
ence, rather than to qualify the student to observe and think for 
himself. 

Special attention should be given to this art of observation, be- 
cause it is the key to science and the first exercise in practice. The 



2 DISEASES OF WOMEN. 

systematic way in which, knowledge is presented in books and by 
oral instruction enables the student to acquire facts in all branches of 
learning, and to classify them. The mental training obtained in the 
study of mathematics and logic prepares men to make reasonable 
deductions from the facts obtained ; but in institutions of learning, 
thorough training in the art of observation is seldom given. 

This lack of preliminary education adds greatly to the labors of 
the student, because he is obliged to acquire knowledge while he is 
not in possession of the means of obtaining it, and it is mainly be- 
cause of this defect that practitioners of medicine are led into error 
in making diagnoses. They fail to observe all the facts, and hence 
their deductions are liable to be incorrect. 

Acute, clear perception is a gift which all do not possess in a 
high degree, but it can be cultivated in those of ordinary intelli- 
gence, and it should be by those who intend to practice medicine. 
The practical study of the elements of natural science, which should 
constitute a large share of the early education of those destined for 
the profession of medicine, aids much in cultivating the faculties 
concerned in observation. So also the arts, especially drawing, 
painting, and sculpture, help to qualify for the actual m professional 
life. The trained eye and hand of the artist are most valuable in 
acquiring the art of medicine and surgery, and a share of the days 
of youth spent at an art-school will save much time and perplexity 
in the medical school as well as in subsequent professional life. 

The first lesson is to obtain a familiarity with the general appear- 
ance of the body in health, its structure and the uses of the various 
organs, the process of development, the slight deviations from the 
ideal or highest type which occur within the range of health, and 
finally the relations of the being to his environments or conditions 
of life. A portion of this subject will be fully discussed in the 
chapter on the development and structure of the sexual organs of 
woman, and the conditions of life which are suitable to her develop- 
ment, growth, and maintenance. Subsequently the derangements 
of the body from disease and injury will come in. for the greater 
portion of time and attention. Here it is that the highest per- 
ceptive power is needed, and the most painstaking attention to ob- 
servation. 

The fact should be kept clearly in mind that a knowledge of the 
science of medicine does not give skill in the art of practice, how- 
ever much it may help in acquiring that art. Men profoundly 
versed in the science of medicine may be poor practitioners; and 
others, whose knowledge of the science is very limited, may attain 



METHODS OF OBSERVATION. 3 

some reputation in practice ; but the best qualified physician is he 
who knows most of both the science and the art. 

The subject for present consideration is the method of investi- 
gation to be adopted in practicing the art of gynecology. Before 
beginning the actual work of examining patients, it is necessary to 
know how to do so. 

There are several methods of investigating the sick and injured 
given in text-books and taught in the medical schools, but most of 
these are better adapted to general practice than to special depart- 
ments of medicine. The methods which I desire to present here are 
circumscribed, and perhaps less complicated, because they are Kmited 
to the diseases peculiar to women. 

In examining patients it is well to first settle definitely in the 
mind the object to be attained and how to attain it. Some rational 
system of investigation should be mastered in all its details before 
undertaking actual practice. To engage in clinical study without 
such preparation is like trying to read a language without knowing 
its alphabet. 

The system advised is — first, to obtain all the facts regarding the 
case in hand ; second, to arrange these facts in their natural relation 
to one another ; and, finally, to make deductions from the data thus 
obtained. These suggestions will be easily remembered in the fol- 
lowing order and association : observation, classification of things 
observed, and conditions indicated by the sum of the information 
obtained. 

The examination of a patient should begin by a general inspec- 
tion ; and, in order to make that inquiry complete and profitable, 
certain questions should be raised in the mind of the examiner ; such, 
for example, as. What is the general appearance of the patient under 
observation ? "What size ? Regular or defective in general outline ? 
Lean or corpulent ? What temperament ? Is the face pale or flushed ? 
Languid or vigorous ? Sad or cheerful ? Calm or excited ? Intel- 
ligent or stupid ? What diathesis is indicated, if any ? In short, 
does the general physiognomy indicate health or disease ? 

All these interrogations are made by looking critically at the 
patient. There are so many questions to be answered in this con- 
nection, that one may find some diflSculty in promptly remembering 
them ; but by constant practice the mind and eye can be trained to 
take advantage of a rule of observation employed by critical investi- 
gators in other arts, which is this : having a type of normal organi- 
zation in mind, the observer is able to scan a given case, and detect 
any deviation from that standard of healthy formation and appear- 



4 DISEASES OF WOMEN". 

ance. The artist, in looking at a picture or statue, does not neces- 
sarily question every line of the drawing or form by itself, but 
his trained eye catches any defects that there may be in the work 
before him. 

The classification of facts is simply putting together those which 
are similar in character. The arrangement of material things in 
groups is familiar to all. A well- arranged library, in which all 
books pertaining to a given subject are placed side by side, is a fair 
illustration of this kind of classification. Facts and ideas can be 
arranged in the mind upon precisely the same principle. The ad- 
vantage of classification is that it aids comprehension and memory. 
By recalling one group of facts which have been associated in the 
mind, the rest will follow in easy and natural order. There are two 
methods of classifying the information contained in the clinical his- 
tory of a patient. One is to obtain all the facts possible, and then to 
arrange them in order. The other is to classify them at each step 
of the examination. The former method requires a mental grasp 
and tenacity which few possess, and therefore I would advise the 
latter. 

The information obtained by inspection may be classed under 
four heads : 1. The original character of the organization, whether 
perfect or imperfect in structure and function. 2. If imperfect, 
whether from imperfect development, causing lesions of form or 
lesions of structure, or from inherited or acquired disease, and inher- 
ited tendencies to disease, known as diathesis. 3. Evidences of dis- 
ease, expressed in the face, either acute or chronic. 4. The tem- 
perament ; which simply means the preponderance of a certain 
portion or portions of the organization. 

To illustrate the value of this process of general inspection of 
patients, the partial history of a case seen in private practice will 
sufiice. A lady called to consult me regarding her son, a little fel- 
low seven years of age. After a very brief survey of the patient, I 
saw enough to satisfy me that he had recently had scarlatina, and 
that when a child he had suffered from sore eyes, and that his father 
had been subject to rheumatic pains in years gone by. The mother 
acknowledged that I was right in every particular. A glance at the 
boy showed that exfoliation of the cuticle, which occurs after scar- 
latina, was still going on ; the face was pale and puffy, indicating 
commencing dropsy from acute nephritis, a sequel of the eruptive 
fever. I also noticed that he had a scar upon the cornea of each 
eye, the result of a former keratitis. The form of his nose and the 
character of his teeth indicated an inherited syphilis ; and from the 



METHODS OF OBSERVATION. 5 

appearance of bis mother and other facts known to me, I presumed 
that the father was the one who had transmitted the specific disease. 

The age of the patient should be ascertained, because that sug- 
gests the possible existence of the diseases which are likely to occur 
at certain periods of life. Care should be taken to compare the real 
and apparent age, in order to ascertain if the patient is prematurely 
old, or well preserved. This interrogation will also serve to keep in 
mind the fact that, in early life, acute diseases prevail, while degen- 
erations are usually limited to advanced life. 

It is important to know the social relations of a patient — that is, 
whether she is married or single. If married, she is liable to the 
diseases and accidents attendant upon child-bearing. If she has 
never been pregnant, her sterility may have resulted either from 
choice, or because of some defect in her organization. Women who 
are single are, by reason of that fact, limited in the range of diseases 
of their sexual organs, and this may be taken for granted unless evi- 
dence to the contrary is obtained. 

Having made a general inspection of a given case, and ascer- 
tained the age and social relations, an examination of the various 
portions of the body should next be made in systematic order. To 
do this conveniently, one group of organs or one system should be 
examined at a time. The various systems are classified as follows : 



THE NERVOUS, NUTRITIVE, MUSCULAR, AND SEXUAL 

SYSTEMS. 

The first three are subdivided as follows : The nervous has two 
grand divisions, the cerebro-spinal and organic. The nutritive has 
four subdivisions, the digestive, circulatory, lymphatic, and excre- 
tory ; and the third has the osseous and muscular. 

The present purpose is to outline the methods of investigating 
the sexual system, but, in order to do that successfully, it is necessary 
to be able to examine the whole body. ]N^o one can be a trustworthy 
specialist without having a thorough knowledge of the whole organi- 
zation. All the parts of the body are so bound together by mutual 
relations that one can not accurately diagnosticate the diseases of 
one portion without knowing the condition of all the others. On 
account of that fact I must refer to the principles upon which the 
examination is made of parts other than the sexual system. 

Briefly, it may be stated that the two principal subjects of in- 
quiry are the condition of the function and structure of the organs 
under examination. Perverted function of the cerebro-spinal divis- 



6 DISEASES OF WOMEN. 

ion of the nervous system is manifested through derangements of 
sensation and motion, and abnormal states of the organic nerves is 
indicated when nutrition is deranged, while the organs of nutrition 
are free from structural disease. The condition of the circulatory 
system is indicated by the color of the skin and mucous membranes, 
the character of the pulse, and the heart-sounds. 

The general nutrition may be estimated by the appetite for food, 
the excretions, and the state of the tissues generally. These are 
meager hints, but, if kept in mind while examining cases in the de- 
partment of gynecology, will guard against the mistake of overlook- 
ing affections of the general system, which might modify or cause 
diseases of the sexual system. 

In applying the principles already hinted at in the investigations 
of special diseases of the sexual organs, we find that morbid action is 
manifested by symptoms and physical signs. The symptoms may 
be classed under three heads : First, deranged nerve-action ; sec- 
ond, deranged functions of the organs affected ; and, third, modified 
locomotion. 

First Class (nerve-symptoms). — Pelvic pains not specially local- 
ized ; sacral pain ; pain of certain pelvic organs ; pains beginning 
in the pelvis and radiating to other parts of the body. 

Second Class. — Derangements of function, such as deranged men- 
struation ; sterility ; abnormal discharges ; deranged function of the 
bladder and rectum. 

Third Class. — Aggravation of any or all of the above-named 
symptoms, by standing, walking, or other muscular exercise. 

Keeping this classification in mind, questions will suggest them- 
selves, the answers to which will determine the presence or absence 
of these symptoms. One should know the symptoms which belong 
to a given disease, and then ascertain if they are present by asking 
questions of the patient. Correct testimony will more surely be ob- 
tained in this way than by depending upon the voluntary statements 
of the person examined. 

The following plan will be of service in obtaining the symp- 
toms referred to in the three classes given above : First, ask if the 
patient has pain and where it is located. Ascertain also if this pain 
is connected with any of the functions of the pelvic organs. Then 
obtain the history of the functions of the sexual organs, in the 
past and present. These facts can be obtained from the patient 
herself, aided perhaps by some one who knows her well. Some 
practice is necessary to acquire skill in taking testimony, the value 
of which depends largely upon the physician's ability to make the 



METHODS OF OBSERVATION. 7 

patient answer his questions correctly. Such questions as the fol- 
lowing regarding the menstrual function should be asked : At what 
age was the menstrual function first established ? At what periods 
of time has it recurred ? How long does it continue each time ? 
What are the quantity and character of the flow ? Is it attended with 
pain, and if so, where is the pain located, and at what time does it 
occur in relation to the menstrual flow ? Has menstruation always? 
been attended with pain, or only for a limited period in the historj 
of that function ? And, finally, is menstruation attended with de 
rangements of any of the other functions of the body ? 

From the answers to these questions two points can be decided : 
First, whether menstruation has been performed normally during 
the whole or part of the patient's menstrual period of life ; and, sec- 
ond, if any derangement of that function exists, whether it be in 
character, recurrence, duration, or quantity. 

Next in order comes the history of reproduction. Has the pa- 
tient had children, and if so, how many, and when ? Has she mis- 
carried ? H she has, at what period of gestation, and at what time 
in relation to birth of living children if she has had any ? Was 
there anything abnormal in her pregnancies, confinement, or recov- 
ery from labor ; if so, w^hat ? The answers to these questions will 
determine whether the present conditions date back to some of the 
diseases or accidents of pregnancy or parturition. If the history so 
far obtained indicates any disease or functional derangement of the 
sexual organs, and there is any accompanying affection of the general 
system, the question arises, regarding the relations which they sus- 
tain to one another. That question can frequently be settled by 
ascertaining which of the two affections, the local or general, ap- 
peared first. The one which precedes is frequently the cause of 
that which follows. 

Thus far we have been dealing with symptoms which, as a rule, 
reveal only derangements of function. They are but expressions 
of disease, and do not in all cases indicate the conditions of the 
organization which cause the derangement of function. 

This brings us to the final division of our subject, viz., the phys- 
ical signs of disease. These are the physical evidences of change 
of structure. There are exceptions to the general rule that these 
physical evidences are always present, but they are few in number, 
and therefore may be omitted in our general consideration of the 
subject. 

The changes of structure and organization in the sexual organs, 
which are expressed by physical signs, are as follows ; 



B 



DISEASES OF WOMEN. 



Changes of position, form, size, consistence, composition, color 
or appearance, and degree of sensitiveness. 

The means of obtaining physical signs are the tonch — single 
or bimanual — palpation, percussion, speculum, sound, probe, curette, 
exploring-needle, uterine dilator, and microscope. 

The art of employing these means next claims attention. 



EXAMINATION BY THE TOUCH. 

This examination is most conveniently practiced when the pa- 
tient is placed upon a suitable table. One that is thirty- three 
inches high, forty-three inches long, and twenty-three inches wide, 
having a projection on the right-hand comer upon which to rest 
the feet, answers better than any table or chair that I have ever seen. 




Fig. 1. — Examining table. (The upper part of the foot-rest folds down as the dotted lines 
show, and the support can be pushed in.) 

The patient should be placed upon the back, with the pelvis as 
near the end of the table as possible, permitting the heels to rest 
upon the table also, while the thighs are flexed upon the body and 
the legs upon the thighs. A sheet held by the edge in both hands 
is drawn over the limbs from the feet upward, at the same time 
that the skirts are pushed up out of the way. This protects the 
patient from exposure. 

In this examination the index-finger of the right hand is gener- 
ally employed, but both right and left should be educated, because 
it is sometimes difficult to examine that side of the pelvis which 
faces the back of the hand used. In critical cases, therefore, it may 



METHODS OF OBSERVATION. 



9 




Fig. 2. — Bimanual examination. 



be necessary to employ both hands, first one and then the other, in 
order to complete the examination. In the majority of cases it is 
requisite to employ 
the bimanual method, 
as it is termed — that 
is, while one finger is 
introduced into the 
vagina, the fingers of 
the other hand are 
placed upon the abdo- 
men at the pelvic in- 
let, and by pressure 
the parts are brought 
down to within near 
reach of the finger in 
the vagina. Fig. 2 
illustrates the mode 
of making this exam- 
ination. This method 
is quite satisfactory in spare patients with lax abdominal muscles ; 
but when the muscles are tense, and when the walls of the abdomen 
contain a thick layer of adipose tissue, the examiner will find great 
difficulty in practicing it. In such unfavorable conditions, when the 
diagnosis is obscure, much will be gained by using an angesthetic. 

Examination of the pelvic organs through the rectum is of great 
value. In this method the touch is practiced in the same way as in 
that already described. 

There are other methods practiced, such as introducing two fin- 
gers into the vagina, the index and the middle ; and the introduction 
of the whole hand into the vagina or into the rectum. Simon's 
method is to first dilate the sphincter-ani muscle, and then pass the 
whole hand into the rectum as far up as need be. Extraordinary 
advantages have been claimed for this method, which brings all the 
pelvic organs within the grasp of the examiner ; but it has proved to 
be dangerous, and, owing to the fact that pressure benumbs the hand, 
it is more difficult than it appears to be theoretically. It should 
not be practiced, except in rare cases in which it is of vital impor- 
tance to make an accurate diagnosis that can not otherwise be made. 
These methods are not without danger, and always do less or more 
violence to the parts, and are only practiced in rare and obscure 
cases, mostly those of tumors. Dilatation of the urethra sufficient to 
admit the finger has been practiced and advised for the pui-pose of 



10 DISEASES OF WOMEN. 

aiding in the exploration of tlie pelvic organs, but the informatioD 
gained in this waj does not compensate for the suffering and danger ; 
hence the practice is rarely called for, and still more rarely admissible. 

Digital Touch by the Rectum. — This method is generally resorted 
to when some obscure, abnormal condition has been discovered by 
the vaginal touch. Much satisfactory information can be obtained 
in this way, especially regarding the posterior wall of the uterus, 
the ovaries, and the sac of Douglas. 

The bimanual method of practicing the rectal touch is the same 
as the vaginal. Pressure upon the hypogastrium with the external 
hand gives the conjoined aid, as in examining by the vagina. 

Vesico-Vaginal Examination. — In this method a sound is passed 
into the bladder while the finger is in the vagina. By this means 
certain states of the vagina, urethra, and bladder are investigated. 

Vesico-Rectal Examination. — This is the same as the vesico- vaginal 
except that the finger is introduced into the rectum. It is the more 
valuable of the two in exploring all that lies between the bladder 
and rectum. 

Palpation. — Whenever the touch discovers anything abnormal^ 
as a tumor, an enlargement of the uterus, or products of inflamma- 
tion, additional information can be obtained by abdominal palpation. 
This is accomphshed by manipulating the abdomen so as to outline 
the part in question, and to test its sensitiveness, mobility, and 
density. Both hands are usually employed in this examination. 

Percussion. — It is unnecessary to describe the manner of practicing 
percussion. Suffice it to say that percussion is practiced in exactly 
the same way in exploring the abdomen as it is in exploring the 
thorax, the object being to test the density of the abnormal part and 
outline its relations to the abdominal organs. 

Palpation and Percussion Conjoined. — This consists in resting the 
fingers of one hand at one point on the abdominal walls and making 
percussion at another point. Its chief object is to ascertain if there 
is fluid present ; this is shown by fluctuation. There are three ways 
of accomplishing this : The lirst is to select points on the distended 
abdomen directly opposite one another, resting the fingers hghtly at 
one part, and percussing at the other. This is known as the dia- 
metrical method. The second, the peripheral method, is to take 
points on a section of the abdomen and manipulate in the same way. 
The third consists in resting the fingers at one point and making 
pressure at the other, to see if the part is wholly movable or partially 
so. This differs from the others essentially in substituting inter- 
rupted pressure for percussion. 



METHODS OF OBSERVATION-. 



11 




Fig. 3. 



speculum. 



The Speculum. — This instrument is twofold in its use. It is one 
of the most important aids in the investigation of disease, and at 
the same time a 
necessary instru- 
ment in treat- 
ment. A great 
variety of spec- 
ula are used, 
but two answer 
all requirements. 
Sims's speculum 
and Cusco's bi- 
valve, slightly 
modified, answer 

every indication. In fact, Sims's speculum is all that is needed, ex- 
cept when an assistant or nurse can not be obtained to hold the specu- 
lum, then Cusco's 
may be employed 
with advantage in 
examining the cer 
vix uteri, and for the 
purpose of making 
applications thereto. 
In using Sims's 
speculum it is ne- 
cessary to have the 
patient upon the 
table already de- 
scribed, which should be near a window giving a good light. Oc- 
casionally it may be necessary to examine a patient upon the bed, 
but this is difficult, and should not be undertaken until the ex- 
aminer has acquired by practice great facility in the use of the 
instrument, and only then, when it is hnpracticable to place the pa- 
tient upon the table. 

The position of the patient should be on the left side, semi-prone, 
with the left arm behind the back, the head upon a low pillow, and 
near the right-hand side of the table, the limbs drawn up, the right 
limb above and in front of the left, and the pelvis at the end of the 
table on tlie left-hand side. Fig. 5 illustrates tliis position. 

In order to place the patient in this position, she should stand upon 
an ottoman or low chair, with her left side toward the end of the 
table. The skirts on the left side are then raised, and she is directed 




4. — Cusco's bivalve speculum. 



12 



DISEASES OF WOMEN. 



to sit down on the table ; her left hand is placed behind the back, 
and she is made to lie down on the left side, inclining forward. The 




Fig. 5. — Sims's position, seen from above. Fig. 6. — Nurse holding Sims's speeuium. 



limbs are at the same time drawn up and placed in proper position. 
The skirts are then pushed up on the right side, and at the same 



METHODS OF OBSERVATION. 



13 



time a sheet is drawn over the limbs and arranged so as to expose 
the labia only. 

The speculum is introduced by separating the labia with the 
fingers of the left hand, holding the instrument in the right hand 
bj the handle ; the point of the blade is placed upon the posteri- 
or commissure, and, while backward pressure is made, the speculum 
is passed into the vagina. Care should be taken not to touch the 
meatus urinarius. The free blade is then grasped with the right hand 
by the nurse or assistant, while with the left she raises and supports 
the natis and labium on the upper or right side. The position of the 
one who holds the speculum should be with the left side toward the 
patient, the fingers of the right hand surrounding the blade, while the 
thumb rests in the inside of the blade. The elbow should rest 
against the side, as a point of purchase to give ability to make steady 
traction. The left arm should rest upon 
the right hip of the patient, while the 
hand supports the labium and natis to keep 
them out of the way (Fig. 6). Careful 
training is required to enable one to hold 
the speculum properly. The chief and 
essential requirement is to maintain the 
instrument for any desired length of time 
in the position in which the operator may 
choose to place it. The objects to be at- 
tained by the use of the speculum are, to 
distend the vulva by making traction upon 
the posterior commissure, and at the same 
time to draw the whole fioor of the pelvis or perinseum backward 

toward the sacrum, away from the pelvic 
organs above, which, from the position of 
the patient, gravitate toward the abdomi- 
nal cavity. By these means the vagina is 
distended by atmospheric pressure, which 
gives space for the admission of light, and 
room for inspection or manipulation in 
operating. These facilities can be extend- 
ed by changing the position of the specu- 
lum in the foUowino- manner: The as- 
sistant who holds the instrument can, by 
rotating the hand, cause the point of the 
blade in the vagina to describe the arc of a circle (Fig. T). By 
moving the hand forward, the blade is made to point" back wai-'d 




Fig. 7. — The raovements of the 
speculum. First movement. 




Fig. 8. Second movement. 



14 



DISEASES OF WOMEN. 




toward the rectum ; and bj moving the hand backward, the blade 
is caused to point forward (Fig. 8) ; and, "finally, by raising or lower- 
ing the hand, the speculum is made 
to reflect the light upward or down- 
ward to either the upper or lower side 
of the vagina, according to the re- 
quirements of the examiner ( Fig. 9). 
/ '^^ v| ||||||i >.^^ At the same time that all these 

changes of position are being made, 
the required traction upon the pe- 
rinseum can be maintained. 

In using the Cusco specuhim, 
Fig. 9.-The third movement. ^^i© position of the^ patient is the 

same as for examination by the 
touch. The labia are separated with the left hand, and the instru- 
ment introduced with the blades closed, the direction of introduction 
being downward and inward. When the speculum is in position the 
blades are separated. There is quite often difficulty in bringing the 
cervix into view through this instrument. This can usually be avoid- 
ed by getting the point of the posterior blade well under the cervix 
before separating the blades. This speculum is principally used in 
the treatment of the simpler diseases of the cervix uteri, when an as- 
sistant can not be procured to hold a Sims's speculum. As a means 
of investigation it is quite limited in its use. 

Hunter's Depressor. — This instrument is used to depress the 
anterior vaginal wall. It acts like the anterior blade of a bivalve 
speculum, and is a necessary companion to Sims's speculum. Of 
all the depressors. Hunter's I regard as the best 




Fig. 10. — Hunter's depressor. 



THE UTERINE SOUND AND PROBE. 

There are three kinds of sounds : Simpson's, which is made of 
hard metal, and maintains an unchangeable shape ; Sims's, which is 
of soft metal, and can be bent or molded to any curve ; and a third, 
which is elastic and bends on the slightest pressure, but by its elas- 
ticity regains its original shape. There are two varieties of the lat- 
ter : that made of elastic material like whalebone or rubber, and a 
metallic one, rendered elastic by a spiral arrangement in its mechan- 
ism, known as Jenks's. Simpson's sound is seldom used now, except 



METHODS OF OBSERVATION-. 



15 



in a modified form. It is difficult to use, because its shape can not 
be adapted to different cases ; and it is dangerous, from the fact 
that it will not bend to light pressure. 




Fig. 11.— Sims's probe. 

Sims's probe is made of soft copper or pure silver, both of which 
metals have the quality of being easily molded. It is like the ordi- 
nary probe used in general surgery, only longer and a little thicker, 
and is provided with a handle (Fig. 11). 

The probe which is most generally used, and the one which I 
prefer for ordinary use, is the same as Sims's, only thicker. It is 
stiff' enough to sustain all requisite pressure, and yet can be easily 




Fig. 12. — Whalebone sound. 

molded to any curve. In practice it is well to be provided with 
this one as well as that of Sims. 

The elastic probe is the same in form as Sims's, but is made of 
rubber, gum-elastic, or whalebone (Fig. 12). 

The sound of E. W. Jenks is hollow and spiral for a distance of 
two thirds from the pointed end. This spiral arrangement gives it 
fiexibility. It is also graduated and provided with a sliding sheath 
which is very convenient in measuring the depth of the uterus, the 




Fig. 13. — Jenks's sound. 

arrangement being such that the examiner can run the sheath to- 
ward and away from him, the figures at the end of the sheath near- 
est the handle giving the measurement of the distance from the 
point to the distal end of the sheath (Fig. 13). 

The sound or probe should only be used after tlie position of the 
uterus has been ascertained by a digital examination, and its sensi- 
tiveness tested as far as that can be by the touch. It is very impor- 
tant to know the position of the uteras and its relations to the other 
organs, in order that the sound may be curved to suit the direction 



16 DISEASES OF WOMEN". 

of the canal of the uterus, and to suggest the direction in which the 
instrument should be guided. There are two ways of probing the 
uterus : In the one, the patient is placed upon the back, and the fin- 
ger of the examiner is carried up to the os uteri ; the sound is 
then guided along the finger until it enters the canal, when it is 
passed to the fundus, the handle being depressed to make the sound 
correspond to the direction of the canal of the uterus. The other 
way is to expose the uterus with Sims's speculum, and to pass the 
sound with the aid of the eye. This latter method is the easiest 
and safest, and gives at least as much information as the one first 
described. The vaginal walls being distended by the speculum, 
the instrument is free to accommodate itself to the direction of the 
canal of the uterus, and, aided by sight, the os uteri can be found at 
once. Safety in using the sound does not depend so much upon the 
touch which guides the instrument to the uterus as upon the hand 
that holds and passes it into that organ. There are few who acquire 
the perfection of touch to guide the sound into the unseen uterus 
without using force, which, though very slight, may cause mischief. 

In sounding or probing the uterus in any way, force should not 
be used. This rule should never be violated. 

The Soimd and Palpation Combined. — In this method of examina- 
tion the sound is passed by touch, wnth the patient upon the back, 
and, while it is in the uterus, it is held with one hand ; the other 
hand is placed upon the abdomen, and downward pressure made until 
the uterus is felt. The uterus is then moved by the sound, and the 
movements are detected by the hand upon the abdomen. The in- 
formation obtained in this way will be noted farther on. 

The Curette. — This instrument is used to explore the cavity of 
the uterus in order to detect any abnormal growths which may be 
there, and also to remove portions of such growth for inspection, in 
order to determine their character. The instrument best adapted to 
this purpose is made upon the principle of the Recamier curette. It 
is simply a scoop of small size with a stem of flexible copper or sil- 
ver, the object of this flexibility being to enable the investigator to 
bend or curve it to suit the position of the uterine canal, and also 




14. — Skene's curette. 



that it may bend before doing any damage to the endometrium if 
undue force is inadvertently used (Fig. 14). 

The curette is introduced through a Sims's speculum in the same 



METHODS OF OBSERVATION. 



IT 



manner as the sound, and when once within the cavity of the uterus 
it is passed over the surfaces of the endometrium, and if any pro- 
jections are detected a portion can be scraped oif and removed for 
inspection. The further use of the curette will be again described, 
in connection with the treatment of diseases of the uterus. 

The Aspirator. — This instrument is employed to investigate the 
contents or composition of tumors formed in the pelvis. When the 
question arises whether the tumor present is solid or fluid, and if 
fluid what the character of the fluid is, the use of the aspirator will 
determine. The aspirator used in general surgery answers well ; 
still, a hypodermic syringe, larger than the usual size, and armed with 
a long, slightly curved needle, thick enough at the end nearest the 
syringe to give it strength to bear pressure, is more convenient. 

The method of using the exploring aspirator is as follows : The 
patient is placed upon the back, and the point of the needle is guided 
to the part to be examined, and is then thrust into the mass or tu- 
mor ; the piston is then drawn out, and the fluid, if any be pres- 
ent, is examined. 

Uterine Dilators. — When it is necessary, as occasionally happens, 
to dilate the cervical canal in order to explore the cavity of the 

Fig. 15. — Hanks's dilator. 

uterus, resort must be had to some of the dilators. These are of 
two kinds: The first consists of graduated dilators, which can be 





Fig. 16. — Goodell's dilator, 



passed in rapid succession, such as the dilators of Hanks (Fig. 15), 
and the instruments with expanding blades (Fig. 16). These are in- 
tended to produce rapid divulsion to the required extent. The 
other kind acts by the swelling of tlie material of wliich they are 
made. Of these tents the compressed sponge (Fig. 17), sea-tangle, 
and tupelo (Fig. 18) are in general use. 

It is seldom that tents are required for purposes of examination 
a 



18 



DISEASES OF WOMEN. 



only; the dilators mentioned answer, as a rule. Thej act more 
promptly, and are less likely to cause after-trouble if dilatation is not 
carried to an extent which is seldom necessary for purposes of ex- 
amination. Tents are to be avoided if possible, because of the suffer- 




FiG. 17. — Sponge tents. 



Fig. 18.— Tupelo tents. 



ing they cause, and the danger of inflammation and blood-poisoning, 
both of which misfortunes have followed their use. They expand 
slowly, and cause irritation and pain, w^hich must be endured for 
hours before they accomplish their work. Acting thus like foreign 
bodies and powerful irritants, they are not without danger. The 
dilators act more promptly, and are less likely to induce inflamma- 
tion, and, although they cause pain and irritation, these are of short 
duration. 

The Concave Mirror. — This is commonly known as the head-mirror, 
and is used in the practice of laryngoscopy. It is also of much use 
in speculum examinations when a good light can not be obtained. 
In emergencies occurring at night, the mirror enables the surgeon to 
use artificial light with perfect satisfaction. Placing a lamp by the 
side of the patient in front of the examiner, the light can be reflected 
into the vagina so as to expose the parts in a very 'perfect way. 
Facility in the use of this mirror should be acquired, as it is at times 
indispensable. 

The Microscope. — A careful scrutiny of the minute structure of 
pathological specimens is always necessary to complete diagnosis, 
lience the microscope should be placed high in the list of means for 
exact observation and investigation. All that need be done in this 
connection is to remind the reader of the fact. A knowledge of 
the microscope and its use must be obtained elsewhere. The prog- 
ress in microscopic investigation has been go great that many men 
in active practice have neither the time nor the ability to make their 
own microscopic investigations. When such is the case, the duty of 
the gynecologist clearly is to seek the aid of the microscopist that he 
may obtain through him the required information. 



METHODS OF OBSERVATION. 19 

Anaesthesia. — There are certain cases that can not be examined 
without being anaesthetized. When there is great tenderness of 
the pelvic organs, and the abdominal muscles are in a condition of 
spasm, which render the examination wholly impossible or suffi- 
ciently unsatisfactory to leave a doubt in the mind, then ether should 
be given to the extent of complete angesthesia. The relaxation which 
this affords simplifies all investigations in a very marked degree. In 
the investigation of the pelvic organs of insane women and in vir- 
gins who certainly require examination yet can not submit, the 
nitrous-oxide gas is of great value. It acts quickly and pleasantly, 
and has none of the effects during or after its administration which 
are so distressing to those of sound mind and horrifying to the 
insane. 

The mode of administering it is with the apparatus used by den- 
tal surgeons to whom we are indebted for perfecting the apparatus 
for giving this anaesthetic. The gas is condensed in a strong cylin- 
der which holds one hundred gallons. By a valve arrangement it is 
permitted to escape into a rubber bag, from which it is inhaled. 
The inhaler is an ingenious arrangement by which the act of inspi- 
ration opens a valve that permits the gas to be drawn from the 
bag, while the act of expiration closes the valve in the supply-tube, 
and opens another valve for the escape of the impure air. There is 
still another valve under the control of the operator, which admits 
air with the gas, so that when the patient is fully anaesthetized the 
gas can be diluted with air in sufficient quantity to keep up the 
anaesthesia. The cylinder of condensed gas and the inhaler are put 
up in a case convenient to carry. The mechanism of this apparatus 
can be more easily comprehended by examination than by descrip- 
tion, and a little practice will enable any one to use it. 

To be able to recognize the normal and pathological conditions 
which are revealed by the means described requires much practice. 
It greatly aids in obtaining that practice — in fact, it is quite neces- 
sary — to keep clearly in mind what to look for. In order to facilitate 
the memorizing of the objects to be investigated, I have arranged the 
signs under each of the various means of obtaining them as follows : 

Vaginal Touch. — Position, size, shape, and density of the uterus. 

Size and shape of the os externum. 

Presence or absence of discharge from cervix. 

Condition of vaginal walls, perineal body, and recto-uterine space. 

State of the rectum and lower portion of sac of Douglas. 

Position of the bladder and urethra as indicated through the an- 
terior vaginal wall. 



20 DISEASES OF WOMEN". 

Presence or absence of fixation of pelvic organs ; swelling or tu° 
mors in tlie sac of Douglas or broad ligaments. 
. Tenderness at any part. 

Bimanual Touch. — Size, form, and position of the body of the 
nterns. 

Tenderness and mobility of the uterus and other organs and 
tissues. 

Position and state of the Fallopian tubes and ovaries. 

Condition of the bladder. 

Presence of neoplasms and their relation to the pelvic organs. 

Products of inflammation, their location and character. 

Eectal Touch. — Condition of the rectum, posterior surface of the 
uterus, broad ligaments, Fallopian tubes and ovaries, and utero- 
sacral ligaments. 

Vesico-rectal Touch. — Absence of the uterus from its normal 
position in inversion of the uterus, entire absence of the uterus; 
aid to diagnosis in women who are too fat to permit the bimanual 
examination. 

Vesico-vaginal Touch. — Changes in the position of the bladder 
and urethra. Pesults of disease in the vesico-vaghial septum. 

Palpation. — Form, size, and density of tumors or products of in- 
flammation felt through the abdominal walls. 

Percussion. — Density of morbid parts. 

I^ormal resonance. 

Relations of the above. 

Palpation and Percussion Conjoined. — Fluctuation, density, or 
elasticity of morbid parts. 

Speculum. — Appearance of mucous membrane of cervix uteri 
and vagina. 

Signs of inflammation of mucous membrane, 

Pelations of the cervix to the vagina. 

Form of os externum. 

Character of secretions. 

Signs of injuries to the cervix and vagina. 

JS'ature of new growths suggested by their appearance. 

Sound and Probe. — Direction of the canal of the cervix and cav- 
ity of the body of the uterus, in relation to their normal position in 
the pelvis. 

Pelation of the canal of the cervix and cavity of the body to each 
other. 

Straight, deflected, or tortuous state of the cavity of the uterus. 

Long and transverse diameters of the cavity of the uterus. 



METHODS OF OBSERYATIOK 



21 



Caliber of tlie cervical canal, os externum, and os internum. 

Degree of sensitiveness or roughening of the different portions 
of the cavity of the uterus. 

Sound and Palpation Combined. — Displaced uterus may be raised 
up to meet the touch of the hand upon the abdomen for examina- 
tion. 

Mobility of the uterus with or without moving abnormal growths 
m the pelvis or lower portion of the abdomen. 

Curette. — Presence or absence of growths or tumors in the uterus. 

Removal of portions of growths from the cavity of the uterus 
for inspection. 

Aspiration. — Abstraction of fluid (encysted or otherwise) for in- 
spection. 

Dilators, tents, anaesthetics and head-mirror as aids with other 
means of exploration. 




18a. — Ether-inhaler. Its principle is the same as that of the nitrous-oxide appara- 
tus. The reservoir, b, in which the ether is vaporized, is separated from the mouth- 
piece, A, by the long rubber tube. The valves, e, of the mouth-piece permit the 
expired air to escape without coming in contact with the ether-vapor. The valve, d, 
enables the anaesthetizer to administer pure air or pure ether, or any proportion of 
air and ether, f is the rubber tube and stop-cock by means of which the mouth- 
piece is blown up. c is a funnel through which the ether is passed, g is the joint 
uniting tube and inhaler. The advantages of the apparatus are that the ether-vapor 
is warmed, that reinspiration of expired air is avoided, and that the ether may be 
diluted with air to maintain the required anaesthesia. The stage of violent excite- 
ment caused by partial suifocation is avoided, and prolonged anaesthesia can be 
maintained without the slightest imperfection of aeration of the blood. 



CHAPTER 11. 



DEVELOPMENT OF THE SEXTJAL ORGANS. 



The Fallopian tubes, uteras, and vagina are developed from two 
primary elements known as Miiller's filaments. These filaments 
when first visible in the embryo are solid, and are situated on either 
side of the vertebral column, a little in front of and on the inner side 
of two other primary elements, the Wolffian bodies. The changes 
whicli take place in Miiller's filaments during the evolutions of de- 
velopment are as follows : From solid libers, slightly enlarged and 
club-shaped at their upper ends, cavities are formed, and these be- 
come canals. Their lower ends approximate and coalesce, from 
below upward, less than half their length. This change, which 
takes place between the ends of the sixth and eighth weeks of 





foetal life, 
sented in 
and 20. 
stage of 



IS 



repre- 
Figs. 19 
At this 
develop- 



FiG. 19.— Mullcr's 
ducts. 



-Coalescence of 
ducts. 



ment, Miiller's ducts 

Fm.20.-Coaiescenceof ^^^ separated by a 
septum formed from 
their coalescent walls, 
so that the united 
portion shows a right 
and left cavity. 
These two cavities 
are soon converted 
into one, the septum 
disappearing from 
below upward throughout the whole of the united portion of the 
ducts. The lower single canal thus formed is the rudimentary vagina 
and uterus, while the two upper ends of Miiller's ducts form the 
Fallopian tubes (Fig. 21). From this time to the fifth month there 




Fig. 21. 



-Disappearance of 
septum. 



Fig. 22. — Appearance of 
fundus and cervix. 



DEVELOPMENT OF THE SEXUAL ORGANS. 



23 



is an increase of tissue, especially in the upper portion of the canal, 
which renders the distinction between the vagina and uterus appar- 
ent. The upper ends of Miiller's ducts expand and become slightly 
fimbriated at their extremities. The upper portion of the uterus at 
this time is bifurcated and forms the two horns between which the 
fundus is subsequently developed. Fig. 22 shows the organs at this 
stage of development. In the sixth and seventh months the uterus 
increases in size, especially in the cervical portion, which at this 
stage is much larger than the body. There is also an increase of 
tissue between the horns of the uterus which renders their diverg- 
ence less marked. The rugose arrangement (palma plicata) of the 
rudimentary mucous membrane of the cavity of the uterus extends 
very nearly to the fundus, its folds running outward to the uterine 
orifices of the Fallopian tubes. Ele- 
vations appear in rows upon the mu- 
cous membrane of the vagina which 
are the rudiments from which the 
transverse folds are subsequently de- 
veloped. During the eighth and ninth 
months the thickness of the walls of 
the body of the uterus increases, the 
fundus becomes more prominent and 
rounded, but up to the time of birth 
the cervix is larger than the body of 
the uterus. At the time of birth the 
primary development of the uterus is complete, and it changes very 
little in form from that time until the period of puberty. The size 

and appearance of the infantile uterus are 
shown in Fig. 23. The cavity of the uter- 
us and the arrangement of its mucous 
membrane are represented by Fig. 2^1:. 
Fig. 25 gives a side-view of the uterus 
and vagina, and shows their relations to 
each other. At tliis time the cervix pro- 
jects but little into the vagina. 

From the time of birth, when primary 
development is complete, up to the period 
of puberty, the uterus undergoes very lit- 
tle change except during the second den- 
tition. At that time the body increases in 
Fia 25.-lnfantile uterus, an- ^^ becoming more nearlv' eciual to the 

tero-postenor section, scant . ^ c? ., i 

invagination. cervix. The paluia plicata disappeai's 




Fig. 23.— Infan- 
tile uterus. 



Fig. 24. — Palma 
plicata extend- 
ing nearly to 
fundus. 




24 



DISEASES OF WOMEIT. 



from the body of the uterus, excepting one longitudinal fold. The 
uterus gradually descends into the pelvic cavity and the cervix is 
projected down into the vagina a little farther. From this time no 
changes occur worthy of notice until puberty, when secondary de- 
velopment takes place. 

Secondary development consists in a general increase in the size 
of the uterus, especially in the body and fundus, which become much 
larger than the cervix. The length of the uterus is increased. The 
walls become thicker and firmer. The last trace of the palraa pli- 
cata disappears from the mucous membrane of the cavity of the 
body, and the mucous membrane becomes thicker by the formation 
of its glandular tissues. In this way the uterus attains the shape 
and size of maturity. Together with the changes in size and form 
comes a change of position. The uterus descends into the pelvis and 
complete invagination of the cervix occurs. 

Fig. 26 shows the general appearance of the mature uterus in 
outline, and Figs. 27 and 28 represent the relations in which the 




Fig. 26. Fig. 2Y. Fig. 28. 

Figs. 26-28. — Virgin uterus (Sappey) : 26, anterior view ; 27, median section ; 28, trans- 
verse section. 26. 1, body; 2, 2, angles; 3, cervix; 4, site of the os internum; 5, 
vaginal portion of the cervix ; 6, external os. 2*7. 1, 1, anterior surface ; 2, vesico- 
uterine cul-de-sac ; 3, 3, posterior surface ; 6, isthmus ; 7, cavity of body ; 8, cavity 
of the cervix; 9, os internum; 10, anterior lip of os externum; 11, posterior lip. 
28. 1, cavity of body ; 4, 4, cornua ; 5, os internum ; 6, cavity of cervix ; 7, arbor 
vitae of the cervix ; 8, os externum. 

cervix and vagina stand to each other. By comparing Figs. 23 and 
25, which illustrate the infantile uterus, with Figs. 26 and 27, the 
difierence between the results of j)rimary and secondary develop- 
ment will be fully comprehended. 



DEVELOPMENT OF THE SEXUAL ORGANS. 



25 



MALFORMATIONS OF THE UTERTTS. 

The malformations of the uterus are naturally divisible into two 
classes : those that occur during embryonic life, and those that occur 
at puberty, the period when secondary development takes place. 
The first class embraces the greatest variety. Nearly all of these 
maKormations are due to arrest of development at different stages of 
that process. The malformations most frequently seen are the uterus 




a 

Fig. 29. — Double uterus and vagina from a girl aged nineteen (Eisenmann) t a, double vagi- 
nal orifice with double hymen. 

bi partis, uterus duplex, uterus unicornis, uterus bicornis, uterus bi- 
fundalis unicollis, and rudimentary uterus, generally known as ab- 
sence of the uterus. A very rare condition has been described as 
hypertrophy of the uterus, and classed with the malformations. It 
is really not a malformation, but a complete development of the 



26 



DISEASES OF WOMEN. 



uterus during iafantile life. When tlie first evolution in tlie process 
of development — i. e., tlie union or coalescence of Miiller's ducts — 




Fig. 30. — Uterus unicornis from a young child, posterior aspect (Pole) : 5, right Fallopian 
tube ; c, left Fallopian tube exceptionally present ; d d, ovaries ; e, bladder (Courty). 

is arrested, and each duct grows bj itseK, the result is the uterus 
bipartis (Fig. 33). 

The uterus duplex is formed by the coalescence of the ducts, 
with arrest of absorption of the central wall. The development 
goes on, so that in time the whole organ is larger than the normal 
uterus, but it is divided into two by the central wall (Fig. 29). 
Uterus unicornis is produced by a complete arrest of development 
of one of the ducts at the part which should form one half of the 
body and fundus of the uterus (Fig. 30). The uterus bicornis occurs 
as the result of non-union of that part of the ducts which forms the 



Tuba 




v ' / ^i^~i 





Fransen 



Fig. 31. — Uterus bicornis unicoUis (Winckel). 

body and fundus (Fig. 31). The uterus bifundalis unicollis is formed 
by the same error of development as that which produces the uterus 
bicornis and double uterus with the following difference : In the 



DEVELOPMENT OF THE SEXUAL ORGANS. 



2Y 



uterus bifuudalis (Fig. 32) the horns, though not united, are well de- 
veloped and present outlines more nearly like the normal body of 
the uterus and the septum 
formed by the union of the 
ducts at the part which forms 
the cervix. In this it differs 
from the uterus duplex (Fig. 
33). Entire absence of the 
uterus is perhaps unknown, 
unless in monstrosities in 
whom the lower part of the 
trunk is wanting. Rudiment- 
ary uterus is seen occasionally. 
As most frequently found, 
there is a very small cervix slightly, if at all, invaginated, and in 
place of the body of the uterus one or two small solid masses are 




Fig. 32. — Uterus bifundalis unicollis. 




Fig. 33, — Uterus duplex (Cruveilhier). Left walls developed in consequence of pregnancy. 

found from a quarter to half an inch in thickness and about the 
same in length. 

The effect of these malformations as manifested during func- 



28 DISEASES OF WOMEN. 

tional life is quite remarkable. In some there is not the slightest 
deviation from health in the function of the sexual organs. In 
others the results are yerj disastrous. This practically gives two 
classes of malformations according to the effect they have upon the 
health and usefulness of the subject. In the one class the malfor- 
mation does not materially affect the function of the uterus, while in 
the other, the functional action is always imperfect — sometimes im- 
possible. The cases of simple deformity, in which there are suffi- 
cient development and growth of one or both elements of the uterus 
to make the organ functionally competent, have no ill effect upon 
the general usefulness and welfare of the individual. The follow- 
ing case will illustrate this : 

Double Uterus and Vagina. — A mai-ried lady, thirty-two years of 
age, who had borne three childi-en and nursed them, called upon me 
for advice regarding a leucorrhoea which had troubled her since the 
birth of her last child. Her general health had always been ex- 
cellent. Upon making a digital examination, I found the vagina 
normal and also the cervix, excepting that one side of the cervix 
was closely united to the vaginal wall throughout its entire length. 
On the left side of the vagina high up I found a hard mass which 
was also noticed on making bimanual exploration. The first im- 
pression was that she had suffered from a pelvic cellulitis, and that 
the mass on the left side was the remains of its products. This 
idea was given up at once on finding that the patient gave 
no history of any pelvic inflammation. I then suspected that 
there might be a fibroid in the left side of the uterus, which,'' 
by extending the entire length of the cervix, had pushed the 
vaginal wall before it. A speculum examination revealed a ca- 
tarrh of the cervical canal. The uterus had the usual appearance 
of one that had borne children, and the cervix was normal in shape 
and position, except for the peculiar relations of the cervix and 
vagina on the left side, wliich were noticed during the examination 
with the touch. Just within the labium minus on the left side, a pe- 
culiar fold of the vaginal wall was noticed running transversely. 
On raising this fold with the point of the sound it was found to be 
a septum, and there was also discovered another vagina to the left of 
it. Using a smaller Sims's speculum to distend this vagina, I found 
the other cervix which had all the characteristics pertaining to a nul- 
lipara. The passage of a sound showed that the canal of the uterus 
on the left side was not quite so long as the one on the right. It 
was then clearly evident that the patient had a double uterus and 
vagina, and that the right uterus had borne three children, while 



DEVELOPMENT OF THE SEXUAL ORGANS. 



the left uterus was a virgin one. She was attended in her conhne- 
ments by three different physicians, none of whom made any refer- 
ence to this malformation, and it is fair to suppose that none of 
them discovered it. 

This case is of interest as showing the fact that some of the mal- 
formations do not in any way affect the function of the uterus nor 
the general health of the subject. 

"When there is malformation, and the growth of the uterus falls 
so far short of the normal type that functional activity is impos- 
sible, the results are often very unfortunate. The nature of this 
class of cases bears such close resemblance to those in which there 
is arrest of secondary development at puberty, that they may be con- 
sidered together in the following chapter. 

A Unique Case of Double Uterus. —In this case I found a large 
uterus with a well-formed cervix, and directly in front of it a very 
much smaller uterus, 
the cervix of which 
was but slightly in- 
vaginated (Fig. 34). 

On my first exami- 
nation I made a diag- 
nosis of uterine fibro- 
ma. I thought that I 
could outline the tumor 
projecting from the 
uterine wall toward the 
bladder. Subsequently 
I noticed a free dis- 
charge of uterine leu- 
corrhoea issuing from 
a slight elevation on 
the vaginal wall in the 
median line, about an 
inch from the os ex- 
ternum of the larger 
uterus. I passed a 

sound througli the small opening in the wall of the vagina, and found 
that it entered about an inch and three quarters, demonstrating that 
the supposed fibroid was a small uterus. 

I account for this stransje malformation on the theorv that, during 
development and after coalescence of Miiller's ducts, tliese rudiments 
made half a revohition, thus brins^ino^ one in front of the other. 




Fig. 34. — ^Double uterus. 



CHAPTEE III. 

AREEST OF DEVELOPMENT, AND ENTIRE ABSENCE OF FUNCTIONAL ACTIV- 
ITY AREEST OF DEVELOPMENT AND GROWTH IN THE LATER STAGES 

OF EVOLUTION, AND THE CONSEQUENT EVIPERFECTION OF FUNCTION. 

If absence of the uterus or a rudirtientary state of its develop- 
ment is associated with absence or a rudimentary state of the ova- 
ries, there is no tendency to functional action, and the individual 
may not suffer in consequence. She simply remains an imperfect 
and undeveloped being. But when the ovaries are present and 
functionally active, there is generally a tendency to menstruate ; and 
this tendency, unrelieved by a menstrual flow, is often attended with 
great derangement of the general health and much suffering. 

The first evidence of this malformation from arrest of develop- 
ment that comes to the notice of the physician is derangement of 
the menstrual function in some form, or its non-appearance at the 
proper age. On this account it will be well to discuss in a general 
way the nature and characteristics of menstruation before giving the 
history of its derangements, which arise from lesions of structure 
resulting from imperfections of development and growth. 

Menstruation has been the subject of so many speculations re- 
garding its physiology, that it would be unprofitable to enumerate 
them. Suffice it for our present purpose to state that when the uterus 
attains its normal development in a healthy subject it becomes pos- 
sessed of all the requisites necessary to the development of an ovum ; 
but when impregnation does not follow, the mucous membrane of 
the cavity of the body of the uterus undergoes degeneration, either 
wholly or in part, and is exfoliated in a granular state. This degen- 
eration and exfoliation, according to some observers, involve the 
whole membrane down to the muscular walls, while others claim 
that they only affect the epithelial layer. Be this as it may, there ap- 
pears to be a general agreement among the authorities of the present 
time that degeneration and exfoliation occur to an extent sufficient 



ARREST OF DEVELOPMENT. 31 

to expose the smaller blood-vessels of the endometrimn, and to so 
weaken their walls that they give way and hsemorrhage follows. 

This menstrual flow is composed of blood from the vessels, with 
at least the debris of the degenerated and exfoliated epithelium. 
The flow, which lasts for days, subsides, the mucous membrane is 
renewed, and the same high state of anatomical completeness and 
functional capability is restored, when another menstruation takes 
place, and so this function is repeated over and over again, except 
when suspended during pregnancy or lactation, until the end of 
functional activity at forty-five years of age or thereabout. 

During the period of functional activity of the sexual organs, 
from puberty to the menopause, menstruation is an evidence of 
health, and is also essential to health. It is an index of the state of 
the sexual system and also of the general health of mature women. 
Hence its derangements constitute most valuable evidence of the 
presence of disease, while its normal recurrence is an evidence of 
health. In practice it is best to study this function by its character- 
istics, rather than by theories regarding its cause or the reasons for 
its existence. It is on this account necessary to comprehend its nat- 
ural history ; therefore, I propose to give here a synopsis of the con- 
ditions of menstruation. 

The laws which govern this function of menstruation, as given in 
our text-books, are so varied by climate, personal peculiarities, and 
the conditions of life, that a general average pertaining to these 
laws is about all that can be obtained, and this can be used to very 
little advantage in practice. Fortunately, there are certain rules 
which apply to menstruation with great uniformity, and these should 
be clearly understood. The most important of these are the fol- 
lowing : 

1. Menstruation should begin at puberty — i. e., when the woman 
is maturely developed, no matter what the age may be. Increase of 
size may take place by growth after puberty, but all the organs of 
the body should be completely defined, so far as form and structure 
are concerned, before the function of menstruation is taken up. 

2. It should recur at regular intervals ; about every twenty-eight 
days is the average time. A regular periodicity is normal, but the 
duration of the periods often diflPers in different persons. 

3. The discharge should always be fluid in consistence and san- 
guineous in color. 

4. The flow should continue a definite length of time, the dura- 
tion depending upon the habit of each case ; at least there should 
not be any great deviation from this rule. 



32 DISEASES OF WOMEN". 

5. The quantity should be about the same each time. 

There should be no deviation from the first rule. If the menses 
appear before development is complete, both in the sexual organs 
and the general system, it is an error which is either the result of 
disease or of the surroundings of the patient, and generally modifies 
unfavorably her future life unless it can be corrected. The same 
may be said regarding those who fail to menstruate when the devel- 
opment and growth of the body are completed. The other rules re- 
garding the recurrence, duration, quantity, and character of the men- 
strual flow, may vary in different women, but they should be uni- 
form and regular in each person. Whatever the habit may be that 
is established at puberty in a given case, that habit should be main- 
tained through life. Some women menstruate systematically from 
puberty until after bearing a child, then they take up a different 
order of menstruation in regard to all or some of the characteristics 
of that function. That is normal, but it is the only well-marked 
change in habit which is the same in health. 

Obedience to these laws of the menstraal function implies cer- 
tain conditions that are necessary to the fulfillment of these laws. 
These may be briefly stated as follows ; 

1. Maturity of development of all the organs, both of the general 
and sexual systems, and a fair degree of health of all. 

2. A sufficient and well-regulated supply of normal blood to the 
sexual organs. 

3. Normal structure and functional activity of the nerves which 
preside over the action of the sexual organs. 

4. Conditions of life favorable to general health and reproduc- 
tion. This includes food, climate, society, and occupation. 

Allusion has already been made to absence of the uterus and 
also to its rudimentary states in which the menses never appear, and 
because of these marked anatomical defects and absence of function 
nothing can be done by the gynecologist in the way of improve- 
ment. 

There remain to be considered cases in which the conditions of 
menstruation are all present but in an imperfect degree, so that men- 
struation, although established, is performed imperfectly. 

ILLUSTEATIVE CASES. 

TTterns Unicornis ; Imperfect Menstruation and the Results. — A 

woman, twenty -nine years of age, of healthy parents, above the 
average size, and well formed generally, had enjoyed excellent 
health until she was eighteen years of age. About that time her 



ARREST OF DEVELOPMENT. 33 

mammary glands became well developed and she presented all the 
outward characteristics of woman physical and psychical. She then 
began to suffer at stated periods from backache, a sense of fullness 
in the pelvis, and slight leucorrhoea. In a day or two after these 
symptoms came on, and while they continued, she became heavy 
and sleepy, and had a feeHng of fullness in the head and slight head- 
ache. These attacks lasted several days, when they passed off and 
again returned about every month. In the interval her health was 
good and she performed her duties as a domestic. Five months after 
the lirst time that these symptoms appeared, and while she was suf- 
fering from an attack, she had a slight menstrual flow, which lasted 
less than twenty-four hours, and appeared to alleviate her suffering. 
The next month her flow returned in the same way, but all her symp- 
toms were increased. From this time on her menstrual flow re- 
turned regularly, but did not increase in duration or quantity. At 
each recurring menstrual period her suffering increased in severity 
until she was obliged to give up her duties at such times. On one 
occasion when she was trying to do her work while suffering, she 
was exposed to cold and was seized with an inflammation — pelvic 
peritonitis, no doubt — and was taken to the hospital, where she re- 
mained for three months. During that time she took morphine lib- 
erally. From this time her suffering during the menstrual period 
was very great, sufficiently so to keep her in bed, and to require 
large doses of morphine to make life tolerable. Another attack of 
pelvic peritonitis came, and again she was sent to the hospital for 
treatment. She recovered from the acute attack, but her suffering 
at her periods was far greater than ever before. Epileptiform con- 
vulsions came with her pelvic pains, and were repeated frequently 
until the menstrual period passed by. For several years her time 
was spent between her home and the hospital, and in occasional 
efforts to do the duties of a house-servant. 

Condition when First Exmnined. — Having obtained the above 
history from the patient, I observed that she still had all the evidence 
of fair general health, except that, from pain and the use of mor- 
phine, her nervous system was decidedly impaired. 

Physical Signs. — The touch detected a very small cervix uteri 
which projected into the vagina only half an inch. The organs and 
tissues were fixed, and on the left side there was an irregular mass 
which felt like the products of a former pelvic peritonitis. On the 
right side the parts were less elastic than normal, and, owing to an 
exceedingly tense state of the abdominal muscles, the body of the 
uterus could not be felt, neither could the right ovary be positively 
4 



34 DISEASES OF WOMEN. 

made out. From the negative signs, however, I was able to satisfy 
myself that the right ovary was not enlarged, nor was the body of 
the uterus as large as it ought to be. The speculum revealed noth- 
ing of value, but, in using the sound through it, I could pass that in- 
strument into the cavity of the uterus. The canal of the cervix was 
an inch in length, and in its proper position as indicated by the 
sound. When the internal os was reached, the sound turned to the 
right and passed in that direction about an inch. This led me to 
suspect that the uterus was unicornis. To obtain further evidence, 
the speculum was removed, while the sound was left in the uterus. 
The patient was then placed upon the back, and, by the rectal and 
vaginal touch combined, the horn of the uterus above the vagina 
was reached. While making the combined touch, an assistant 
rocked the horn of the uterus with the sound, and I could then out- 
line it with the fingers. It was about an inch in its transverse, and 
only a httle more in its long diameter. The upper end, which rep- 
resented the fundus, appeared to be slightly pointed in place of 
rounded, as is the fundus of the normal uterus. 

Treatment. — There was nothing in the case to give the slightest 
hope that she would derive benefit from any general treatment. 
The removal of the ovaries to stop the tendency to menstruation was 
the only indication apparent to my mind, and, owing to the old adhe- 
sions from the former pelvic peritonitis, the dangers of that opera- 
tion were fully appreciated. The case was explained to the patient 
and the friends who brought her for my advice, and they were left 
to choose between the removal of the ovaries, or no further care on 
my part. The patient, after thinking of the dangers and the pros- 
pects, became very anxious for the operation. Her argument was 
that she was tired of life, and that all her friends were tired of car- 
ing for her, and, if there was one chance in a thousand of being re- 
lieved, she longed for that chance. 

The operation was performed \vith great difficulty, owing to the 
adhesions. The right ovary was completely surrounded with inflam- 
matory products, and was found with much trouble. The left ovary 
was adherent at several points that were easily broken up. There 
was no trace of the left horn of the uterus, nor of the left Fallopian 
tube. The right ovary was located within one inch of the upper 
end of the right horn of the uterus, and there was no well-defined 
Fallopian tube on that side. 

Comments. — This case certainly illustrates fully the great suffer- 
ing that may ai'ise from this degree of malformation. The presence 
of well-developed ovaries which excite a demand for menstruation, 



ARREST OF DEVELOPMENT. 35 

associated with a uterus incapable of performing that function, is 
one of the most unfortunate conditions known to the gynecologist. 
It is evident, also, that the development of the one horn of the uterus 
sufficient to make a slight effort to menstruate only aggravated the 
difficulty. She would perhaps have been better had the uterus been 
absent altogether. 

Incidentally, I may remark that the absence of the tubes in this 
case is evidence against those who claim that they have a leading 
influence in causing menstruation. 

Rudimentary Uterus Bicornis ; Entire Absence of Menstruation. — 
When first examined, this lady was thirty years old, below the aver- 
age size, but well formed, and presented, to outward appearances, all 
the characteristics of her sex. As a child she was rather small and 
delicate, but had good health. At the age of sixteen she passed 
through all the changes of form common to puberty, but never 
menstiniated. When questioned regarding her health at that time, 
she remembered only that she occasionally had slight headache and 
indisposition, but whether these symptoms came periodically or not 
she did not know. At no time was her suffering sufficient to inter- 
rupt her school duties. She was married at eighteen, and, while she 
was affectionate and devoted as a wife, sexually she was perfectly 
negative. Without being very strong mentally or physically, she 
enjoyed good health, and only called upon me at the time she did 
because of some temporary irritation of the urethra which caused 
pain on urination. This gave me an opportunity to examine her 
pelvic organs. The external organs were normal, and the vagina 
also. The cervix uteri was not more than five eighths of an inch in 
diameter. The os externum was small but normal. In the location 
of the body of the uterus two small, oblong, bifurcated bodies were 
found continuous with the cervix. These bodies were about a 
quarter of an inch thick and about an inch long, as nearly as could 
be estimated by the bimanual examination. I regarded them as the 
rudimentary horns of the uterus, which were retroverted. Near the 
upper ends of the horns of the uterus, and a little outside of them, 
two other bodies were found which I presumed to be the ovaries. 
They were about half the size of a fully-developed ovary and of the 
usual form of that organ, except that they were not so flat from 
before backward, and appeared to bs more dense than normal. 
It was evident that the development of the ovaries had progressed 
further than that of the uterus, because they were relatively much 
larger than the rudiments of the uterus. Owing to the fact that the 
patient was of small size, with non-resistino; abdominal muscles and 



36 DISEASES OF WOMEN. 

the rudiments of the uterus retroverted, the examination was easj, 
so that I feel some confidence in giving the physical signs and the 
diagnosis based upon them, believing that they are correct. 

Comments. — This case apparently shows that the ovaries were 
sufficiently developed to influence the changes which occur at pu- 
berty, but were so much under size that they were incapable of the 
highest functional activity, while the uterus was not only arrested 
in its development, but in its growth also ; hence menstruation, even 
in an imperfect way, was impossible. This case is placed in con- 
trast with the preceding one to show that when arrest of develop- 
ment and growth is such as to render functional action entirely 
impossible, a fair degree of health may still be maintained ; while, 
on the other hand, if the development and growth of the ovaries are 
complete, and the uterus is developed sufficiently to make an im- 
perfect effort to menstruate, the health and usefulness of such a 
one is greatly impaired, and a life of suffering generally follows. 

Small Uterus from Arrested Growth; Scanty Menstruation im- 
proved by Treatment. — The patient was a young woman of full size 
and well formed, and of a sanguine, nervous temperament, and a 
remarkably good and well-cultivated mind. She had always enjoyed 
good health excepting when she was fourteen years old. At that 
time she was "working hard at school, and became run down." 
Rest soon restored her, and she began to menstruate at the age of 
fourteen years and six months. Her menses from that time returned 
regularly, but the flow was scanty and lasted only forty-eight hours. 
During the menstrual period, and for several days after it, she suf- 
fered from fullness of the head, restless nights, and a feeling of 
discomfort in the pelvis with general mental and physical indispo- 
sition. She continued in this way until she was mature, the time 
wlien she was first examined. By the touch the cervix uteri was 
found to be rather small, but well formed and in proper relations to 
the vagina. Owing to the rigid state of the abdominal muscles, the 
uterus could not be satisfactorily outlined by the bimanual touch. 
Using the sound through the speculum, the long diameter of the 
uterus was proved to be one and seven eighths inches ; quite a small 
uterus for a woman of her size. Her general health was very good 
indeed, and she would not have sought immediate advice had it not 
been that she was engaged to be married, and was very anxious to be 
relieved from the ill feelings which came in connection with her 
scanty menstruation. 

Treatment. — At her next period she was directed to take a tea- 
spoonful every three hours of the following mixture : Ammon. mur,, 



ARREST OF DEVELOPMENT. 37 

3 ij ; aquae camph., 5 ij, to begin as soon as she felt that the period 
was approaching, and to continue until six hours after the flow 
stopped. ]^ot being used to medicine, she objected to it strongly, 
and during her subsequent periods she took a teaspoonf al of liq. 
ammon. acetatis every three hours, commencing one day before the 
flow began and during its continuance. Immediately after the flow 
ceased, one or more tine punctures were made near the external os, 
which produced considerable bleeding. This was done to relieve, 
as far as possible, the congestion which lingered because it was not 
relieved by the menstrual flow. This was practiced after three pe- 
riods. At intervals of six days during the entire menstrual flow the 
canal of the cervix, including the internal os, was gently dilated 
with graduated sounds. This was done in the hope that it would 
stimulate the nutrition of the uterus. 

After the third month of treatment it was found that the men- 
strual flow had increased in quantity and continued for one day 
longer. A stem-pessary was then introduced, but it caused more 
irritation than was safe ; so, after it had been worn for three days, 
it was removed, and not used again. 

From this time onward the treatment was limited to a mild con- 
stant electric current. One electrode was passed into the uterus, the 
other applied alternately over the sacrum and supra-pubic region. 
This was repeated every six days in the interval between the monthly 
periods. She continued to take the solution of acetate of ammonia 
at each period, but with what benefit is not known. At the end of 
eight months the uterus measured two inches and one eighth in its 
long diameter, and she menstruated between four and "^yq days at 
each time, the flow being much more free and her unpleasant symp- 
toms having all disappeared. She was married then, and I lost sight 
of her for seven months, when she called to consult me regarding 
amenorrhoea, which had existed for two months and was due to 
pregnancy. I heard that subsequently she was conflned, and was in 
quite good health. 

Undersized Uterus from Arrested Growth ; Scanty Menstruation ; 
Sterility ; Incurable. — This woman was thirty years old when this 
history was obtained. She was of medium size, and had enjoyed fair 
health most of her life. During her girlhood she had to work very 
hard in a store, and often suflered at that time from fatigue. She 
developed slowly, and did not menstruate until seventeen years of 
age. During the flrst four years after puberty the menses lasted 
only two days and the flow was scanty. At twenty-two she was 
married, and placed in easier and more comfortable cii'cumstances, 



38 DISEASES OF WOMEN". 

and for about one year the menstrual flow lasted from two and one 
half to three days at each time. She then missed one period, and 
then the menses returned more freely than ever before, which made 
her beheve she had had a miscarriage ; but of this there was no 
proof. When she had been married two years she began to have 
pain of a dull, aching character in the region of the uterus during 
her menses. This pain became more marked as time advanced, and 
gradually the pain extended to the ovaries. These pains were never 
acute, and passed away entirely after menstruation ceased. At 
twenty-nine years of age she had sickness in her family and was 
overtaxed thereby, and her menses stopped for five months, but 
again returned. In the absence of the menses she had leucorrhoea, 
but not before nor since. 

Examination by the touch showed the uterus to be relatively 
long and narrow ; the body was not much larger than the cervix. 
The long diameter as measured with the sound was two inches. 
There was slight tenderness on pressure over the ovaries. All the 
pelvic organs were in normal position. Her general health was 
about as good as it ever had been. 

Treatment. — Sodium bromide, gr. xxx, was given three times a 
day in Yichy water before meals during the menstrual period. This 
relieved the uterine and ovarian pain very much. Between the 
periods the hot- water douche was used until all pain had been relieved. 
The subsequent treatment was about the same as in the case last 
related, with the addition of more extensive dilatation of the cervical 
canal, and she also wore the intra-uterine stem-pessary for six weeks. 
She also took internally phosphates, iron, and strychnia in various 
forms, and for several months. 

At the end of seven months she was free from all pain during 
menstruation, but the flow was no freer, nor did it last any longer. 
The uterus had not in the least increased in size. She was dis- 
missed unimproved, so far as the growth of the uterus was con- 
cerned. 

Comments. — This and the preceding case are placed together to 
show the results of treatment. They demonstrate that the prospects 
of success in increasing the growth of the uterus depend very largely 
upon the age of the patient. The earlier in life that the treatment 
is begun, the more likelihood is there of success. 

Undersized Uterus, its Growth apparently being arrested by Pre- 
mature Sexual Nervous Excitation ; Irregular and Painful Menstruation ; 
all the Symptoms increased by Local Treatment. — This was a single 
woman, twenty-two years old, the daughter of wealthy and educated 



ARREST OF DEVELOPMENT. 39 

parents. She was tall, spare, and of nervous temperament. Before 
puberty she acquired the habit of self-abuse while at school. While 
her general system was not developed, and while w^eak, irritable, dys- 
peptic, and subject to severe headaches she began to give evidences 
of puberty, and her menses iirst appeared at twelve years of age. 
From this time, up to the time of taking this history, she menstruated 
irregularly, the average time between the periods being five weeks, 
but often two, three, and on several occasions five months elapsed. 
The flow was usually normal in quantity, character, and duration, 
although the latter was variable. Pain in the back, pelvis, and lower 
portion of the abdomen always accompanied the menses, and was suf- 
ficiently severe to keep her in bed during that period. The severity 
of the pain was presumably not so great as the patient described. 
Her extreme sensitiveness inclined her to exaggerate her sufferings. 
Neither was the character of the pain so acute and localized as that 
which occurs in flexion of the uterus. Her general health was poor, 
slight mental or physical exercise fatigued her, and if she persisted 
she became so tired that she could not rest. Her sleep was disturbed 
by dreams that were not all dreams, and in the morning she felt 
quite exhausted. Before I saw her she had been treated locally 
and generally by several physicians, some of high standing in the 
profession, and others of questionable repute, and was invariably 
worse after being treated. 

An examination by touch revealed a small uterus slightly retro- 
verted, though that malposition was, I believe, temporary. The 
length of the uterine cavity measured with the sound was a fraction 
less than two inches. With the exception of extreme sensitiveness 
of the pelvic organs generally, there was no other abnormality 
found. 

Local treatment was tried for a short time, but it was found to 
be injurious. She was then given systematic occupation under the 
direction of a skilled attendant. Massage and careful dieting were 
also directed. Her days were fully occupied with short alternating 
periods of mental and physical exercise and rest. Every afternoon 
she took thirty grains of bromide of sodium, and during her men- 
strual periods thirty grains three times a day with eight drops of 
tincture of cannabis Indica. Laxatives were given to regulate the 
bowels, and tonics occasionally when specially required. It should 
be mentioned that she gave up her evil habit as soon as she was made 
to understand its ill effects. Under this general plan of treat- 
ment she improved in every respect. She still suffers at her monthly 
periods, and the menstrual function is still irregular. 



40 DISEASES OF WOME^. 

Comments, — This case is given as a representative of that class of 
cases of delayed or arrested growth of the uteras and the functional 
imperfection which is sure to follow, the primary cause of all being 
the premature excitation of the sexual organs. A sufficient number 
of these cases has been seen and studied to warrant the statement 
that when the habit of self-abuse is begun before puberty it often 
arrests the development or growth, or both, of the uterus, and the 
consequences are far more disastrous than the same practice when 
begun after puberty and completed growth. 

Closely associated with this subject is chlorosis, a condition in- 
volving menstrual derangements due to the same defect of the 
uterus, being associated with lesions of the general system. Chloro- 
sis is a condition which has usually been considered as a disease per 
se, but it appears to me to be rather a peculiar character of organiza- 
tion presenting invariably certain characteristics of structure which 
are unfavorable to high functional activity, and which predispose to 
certain forms of disease. Some authorities, French mostly, believe 
that chlorosis is a disease of the organic nervous system which 
appears at puberty and presents certain changes of nutrition, espe- 
cially in the character of the blood. There is certainly some reason 
for this view of the subject. The functions of the body which are 
under the direct control of the organic nerve-centers are perverted 
apparently by some obscure derangement of organic innervation, but 
this appears to come from some imperfection of the nervous system, 
perhaps mal-development, rather than from some well-deiined dis- 
ease. The German pathologists hold that in chlorosis there is an 
arrest of growth of the circulatory and genital systems ; the heart 
and blood-vessels being undersized and the sexual organs also. 
This certainly corresponds to the facts as observed chnically, and if 
to this be added that peculiar condition of the organic nervous sys- 
tem, which is undehned but probably structural, a type of organiza- 
tion results which presents all the tangible characteristics of chlorosis. 
This is the conception which I have accepted regarding chlorosis, 
which may be defined as an organization in which the circulatory 
and the genital systems are below the normal type in point of devel- 
opment and growth, and in which there is a state of the organic 
nervous system which is also below the normal and incapable of exer- 
cising the highest functional activity. These constitutional conditions 
combine the features of a peculiar temperament and a diathesis; 
the temperament being so marked as to show a tendency to disease 
or diathesis. It would simplify the subject if the term chlorotic 
temperament were used to express this constitutional condition. 



ARREST OF DEVELOPMENT. 41 

Yiewing the subject from this standpoint, it is easy to understand 
that such an organization, while it might act under the most favor- 
able circumstances of life, would be incapable of sustaining the 
more complex functional activities of a mature and fully occupied 
life. It is easy to see, also, that a chlorotic subject, when called 
upon to take up the functions of reproduction, when thus ill-quali- 
iied to do so by reason of anatomical defects, would naturally tend 
to derangements of nutrition in the form of impaired appetite, 
labored digestion, and the anaemia, debility, and mental depression 
which naturally follow mal-nutrition. So, also, would the sexual sys- 
tem suffer because of the undersize of the uterus and, presumably in 
some cases, the ovaries also, together with the imperfect blood- 
supply which, sooner or later, comes from the mal-nutrition. This, 
I believe, to be the true state of the body known as chlorosis, and 
that all the phenomena manifested by such subjects are the outcome 
of their anatomical peculiarities. Whether this be the proper de- 
scription of chlorosis or not, it is the expression in brief of the 
prominent features of chlorotic subjects, and agrees with the facts 
observed in practice. The reason, I presume, for the different opin- 
ions held has grown out of the fact that some have accepted the 
mal-nutrition which is so often seen in the chlorotic, and the conse- 
quences thereof, as the disease itself ; whereas these derangements 
of the nutritive and sexual systems are the outcome of the anatom- 
ical imperfections. The chief object in discussing the subject here 
is, because chlorotic women necessarily suffer from deranged and im- 
perfect menstruation, and they naturally fall into the care of the 
gynecologist, and without some definite idea of the nature of this 
affection its rational management would not be possible. 

From the very nature of chlorosis, it is clearly evident that the 
object of the therapeutist should be to aid in the development and 
growth of the subject while young, in the hope of overcoming the 
natural tendencies to these constitutional defects. After adolescence 
the most that the physician can accomplish is to overcome, as far as 
can be, the mal-nutrition and derangements of menstruation, which 
arise from the constitutional imperfections. 

Arrested Growth of the Uterus, associated with Small Circulatory 
Organs ; Chlorosis. — This patient stated that when a girl she was of 
medium size and quite fleshy, and was said by her friends to look 
strong and healthy, but she was never able to endure much muscu- 
lar exercise. Her appetite and primary digestion had generally been 
good, yet she never required a large quantity of food. Her face 
was rather pale while a girl, and remained so. She never was in- 



42 DISEASES OF WOMEN. 

clined to take active exercise, and, when obliged to do so, respira- 
tion was labored, and slie soon became tired. 

At the age of fifteen she began to show the general form of 
womanhood, but did not menstmate imtil eight months later. From 
that time onward she menstruated regularly, bnt the flow lasted only 
three days, and was not at all free. On several occasions, when 
obliged to exert herself siifiiciently to slightly lower her general 
health, the menstrual flow was almost colorless, and lasted only two 
days. At twenty-one she was married. Her general health remained 
as before, and she proved to be sterile. I saw her when she was 
twenty- eight years of age, seven years after being married. She then 
consulted me regarding her sterility. 

In general appearance she was a typical chlorotic subject. She 
was of medium height, quite fleshy, but not inordinately so; her 
hair was intermediate in color, being neither dark nor light — in 
fact, it might be said to be colorless ; too light for a biTmette, too 
dark for a blonde. If this dark shade had been removed, it would 
have been hair of a dark-flaxen color ; the eyes were a gray-blue and 
very clear ; the sclerotic coat pearly white ; the skin remarkably 
smooth and white. The face was pale, with that greenish-yellow 
hue which must be seen to be fully appreciated. This color of the 
face differs from the yellow, dry skin of the cachectic subject, the 
pallor of anaemia, and the bronze of sunburn. Few blood-vessels 
were visible on the face or hands, and these were very small. The 
pulse was about eighty, but small, more like that of a child. The 
heart- sounds were very clear and distinct, but the impulse was weak. 
The area of cardiac dullness was apparently smaller than usual, but 
this was difficult to make out, owing to the mammary glands being 
large. At the time of my first examination she was feeling more 
than usually languid and weak because of indigestion and constipa- 
tion, which had troubled her for several weeks. Her tongue was 
coated, and her appetite poor. On walking up-stairs quickly she 
suffered from " want of breath." If she stooped down and rose 
suddenly, she had vertigo. Toward night her ankles became 
slightly swollen. Her sleep was often disturbed by dreams. In dis- 
position she was a little sluggish, good-natured, and generally cheer- 
ful, with occasional attacks of mental depression, which occurred 
usually at the menstrual period. 

The pelvic organs were normal as regards general nutrition, except 
that the mucous membrane was ansemic. The position of the uterus 
was normal. The sound showed the cavity of the uterus to be a 
fraction under two inches in length. There was a slight leucor- 



ARREST OF DEVELOPMENT. 43 

rlioea. The menses were regular, lasting from three to four days, 
until four months before she was first seen by me. During that 
time she had had a leucorrhoeal discharge at the menstrual period, 
but nothing more. 

Treatment. — Pil. hydrarg., gr. x ; pulv. ipecac, gr. j, were given 
at bedtime, followed by a saline laxative in the morning. After 
this, a teaspoonf ul of tlie following mixture was given, well diluted, 
before meals : Stryclmise sulphatis, gr. ss ; acid, hydrochlor., 3 j ; 
tinct. cardam. comp., § j ; aquse font., 5 ij. This improved her 
appetite, and her strength increased. When she had finished the 
first mixture, the following was given: Ferri iodid., 3 j ; quinise 
sulph., gr. x ; ext. belladonnse, gr. ij, in pil. I^o. xx, one before each 
meal. These pills were taken with apparent benefit for three weeks, 
when they were stopped, and the following was ordered : Tinct. 
iodin., 3 ij ; potass, iodidi., 3 ss ; syr. simp., § j ; aquse font., § ij ; 
one teaspoonful, after meals, in water. During the following six 
weeks she took the pills one week, and the next week the tincture of 
iodine mixture, alternating regularly. The menses appeared at the 
fifth month after they stopped, but were scanty, and lasted only two 
days. The appetite and digestion were improved, and the anaemia 
was less marked. She also felt much stronger. I then prescribed 
ferri pyrophos., 3 jss ; strychnise sulph., gr. ss ; liq. potass, arsenit., 
3 j ; tr. colomb., § j ; aquse font., § ij. Teaspoonful, in water, after 
meals. This mixture she continued to take for six weeks longer, 
omitting it occasionally for a few days. During the treatment she 
was relieved, as far as possible, from all care, took light exercise in 
the open air, and had a good supply of nutritious food in great vari- 
ety, being restricted only in the quantity of fluids, sugar, and fats 
that she took. The menses continued from this time onward to be 
regular, and the character and duration of the flow were the same 
as they had been in her best former health, but were not improved. 
For several years, indeed up to the present time, which is now five 
years since she was first seen, she has been in fair health, but on 
several occasions, when she ventured to do more than usual, her 
digestion became deranged and her appetite poor. Anemia has 
become more marked, and the menses have diminished, but she has 
promptly applied for treatment, and the use of tonics has restored 
her to her usual rather low standard of health. 

Comments. — This history shows that the patient was not cured 
of her chlorosis, but only relieved from intercurrent attacks of mal- 
nutrition and the consequent imperfect menstruation which she had. 

This is the history of the great majority of such cases when they 



44 DISEASES OF WOMEN. 

come under observation and treatment after puberty. This shows 
that the whole character of the organization is below the highest 
standard, and hence there is a tendency to break down under ordi- 
nary taxation, and the physician can do no more than restore the 
patient to her usual degree of health. 

Chlorosis treated before Puberty, with apparently Good Results. — 
A school-girl, fourteen years old, large enough for her age, and un- 
usually fleshy, was brought to me on account of loss of appetite and 
constipation. There was no evidence of puberty, except that her 
breasts were large, but they were mostly made up of adipose tissue. 
Her general appearance, color of hair and eyes, small heart and 
blood-vessels, white skin, pale face, and disinclination to active exer- 
cise, indicated chlorosis. ]^othing was lacking but the usual anaemia 
and peculiar color of the face to make the case a type of chlorosis. 
She was directed to give up some of her school duties and devote 
more time to systematic muscular exercise and out-of-door life, to 
abstain from fat meat, sugar, and butter, of all of which she was un- 
usually fond, and to live upon lean animal food, flsh, eggs, oatmeal, 
fruit, and brown bread. To relieve her constipation I prescribed 
quin. sulph., 3 j ; ext. belladonnae, gr. ij ; ext. colocynth. comp., gr. 
X, in pil. No. xx; one immediately before each meal. At the 
end of two weeks the bowels were acting too freely. One pill, night 
and morning, before meals, was ordered. These answered for a 
time, but in three weeks it was found that one pill was all that was 
required, and at the end of two months from the time she came 
under treatment, pills were given up altogether. She was then put 
upon the following : 

]^ Hydrarg. chloridi corrosivi g^- j- 

Liquor arsenici chloridi f 3 j. 

Tr. ferri chloridi. 

Acid, hydrochloric, diluti aa f 3 iv. 

Syrupi simplicis 5 ij- 

Aquae q. s. ad 5 ^j. 

M. Sig. : A dessertspoonful, well diluted, after each meal. 
This is known as the mixture of the four chloiides, and is said 
to have been first used by Tilt, of London, and was introduced to 
the profession of Philadelphia by the late Dr. A. H. Smith. This 
medicine was given for one month, then omitted for two weeks, and 
again taken for one month. After this, she was given iodide of 
iron in small doses for two months. In summer she was sent to the 
mountains, and encouraged to ramble in the open air, to drive, and 
occasionally ride on horseback. The diet that was first recom- 



ARREST OF DEVELOPMENT. 45 

mended was continued, except that she occasionally indulged her 
fancy for sweets. 

Under this course of treatment she lost flesh, and grew taller and 
stronger. Her pulse was markedly improved, and her appetite con- 
tinued to be very good. At the age of fifteen years and three 
months she showed evidences of maturity, and simultaneously her 
appetite became somewhat capricious ; backache and headache occa- 
sionally troubled her, and she was at times depressed. The mixture 
of the chlorides was resumed and continued for one month. Her 
usual order of life was continued, except that she did not ride on 
horseback, and was carefully guarded from overtaxation, mental 
and physical. The menses appeared and continued for four days 
normally, and were not attended with great pain. In six weeks the 
flow returned, and lasted the same length of time. From this on- 
ward for one year the menses were normal. After that, she went 
to a higher school, and tried to make up for lost time in her studies. 
During this time she was not seen, i. e., for about one year and four 
months. Then she called upon me, and the following history was 
obtained : Her appetite was capricious, and her bowels constipated ; 
she had headache often ; slept in a restless, dreamy way ; had pain 
in the praecordial region and dorsal portion of the spine ; was easily 
frightened, and had palpitation of the heart on taking exercise. 
The menses were delayed for two weeks, and when they returned the 
flow was scanty, and lasted only three days. At this time she had a 
more marked chlorotic appearance of the face than at any time 
before. The pills previously prescribed were given to keep the 
bowels regular, and the mixture of chlorides was given for one 
month, and after that she was given twenty minims of the sirup of 
the iodide of iron three times a day. The thought of falling behind 
in her studies grieved her so much, that she was placed under the 
care of a governess, who interested her in her studies but did not 
harass her. 

The menses became normal again, and she regained her general 
health, and has since continued well. She is at this time married, 
and the mother of one child. 

Comments. — It is not possible to prove that this patient would 
have become a well-defined chlorotic subject, but I am disposed to 
believe that she would, had she been neglected, as most of these cases 
are. In my clinical record I find several cases of this kind, and most 
of them have been greatly aided by care and medication similai- to 
that used in the management of this case. The benefit of treatment 
has been most marked in those who came under care early in life. 



46 DISEASES OF WOMEN". 

Those who had no treatment until after puberty, and were suffering 
from all the symptoms of typical cases were improved by treatment, 
so far as obtaining relief from deranged digestion and neuralgia, and 
to some extent from anaemia, but they still maintained their consti- 
tutional peculiarities, with a tendency to recurrence of the anaemia 
and menstrual derangements. 

In those who married early and bore children (a not unusuul 
thing for those in whom chlorosis is not marked), there was a notice- 
able predisposition to albuminuria and puerperal convulsions. Such 
cases also tend to inertia of the uterus and post-partum hsemorrhage. 
They very generally suffer from anaemia and nervous exhaustion dur- 
ing lactation. 

A Marked Case of Chlorosis, complicated with. Gastric Derange- 
ment. — The patient was a domestic, twenty-three years of age, and 
presented all the characteristics of chlorosis in a typical degree. 

She had suffered repeatedly from amenorrhoea, but had always 
responded to tonics sufficiently to resume her duties in a few weeks. 

She was attacked with vomiting, her strength failed rapidly, 
and she was unable to leave her room for weeks. When she took 
food it gave her distress, until it was rejected. Sometimes food 
would be vomited after having been retained in the stomach nearly 
an hour, but it was not in any degree digested. 

Gastric ulcer was suspected, although she had never vomited 
blood. She was given peptonized milk as the only food. This she 
retained in increasing quantity, and gradually regained her usual 
health. 

Comments. — This case shows the strong characteristics of extreme 
anaemia in chlorotic patients. I believe that the stomach is unable 
to digest food because of the anaemia, and this causes the vomiting. 
In such cases the peptonized food is of the greatest possible value. 

Menstrual Derangements from Causes independent of the Sexual 
Organs. — This class of menstrual disorders is closely related, in the 
matter of diagnosis, to those deranged functions of the uterus due to 
anatomical lesions; hence the subject may apropriately be dis- 
cussed here. It is only necessary to call to mind all the condi- 
tions necessary to menstruation to see plainly that constitutional 
diseases, acute and chronic, as well as functional disturbances of 
the nervous system, would act unfavorably upon the functions 
of the genital system. As a general rule, any constitutional affec- 
tion which impairs nutrition and reduces strength very decidedly 
will affect menstruation. This is certainly the case when the gen- 
eral depression continues for any great length of time. The best 



ARPwEST OF DEVELOPMENT. 47 

example of tliis is seen in phthisis pnlmonalis. In the advanced 
stages of this disease the menses usually stop altogether. The 
uterine function ceases under these circumstances, simply because 
the general system is unable to sustain it. In acute diseases, such as 
pneumonia or typhoid fever, menstruation may be interrupted for a 
period or two, but it usually reappears when the patient fully re- 
covers from the constitutional disease. On the other hand, in degen- 
erative diseases, such as organic diseases of the liver, lungs, heart, or 
kidneys, the menses often become irregular and scanty or profuse, 
and finally stop altogether during the remainder of the invalid's 
life. So, also, severe shocks or over-taxation from shock, exposure 
to cold, fear, grief, and extreme mental work, may cause the menses 
to temporarily cease. Again, either of the constitutional conditions 
referred to above may retard the first appearance of the menses if 
they are active at the period of puberty, even though the develop- 
ment and growth of the genital organs may not be arrested. 

Amenorrhoea, or delay of the advent of the menstrual function, is 
the rule when these causes exist. There are exceptions to this rule, 
as, for example, valvular lesions of the heart and cirrhosis of the 
liver, may cause menorrhagia, and nervous derangements may cause 
premature menstruation. 

The diagnosis in such cases is usually easy. By the time that the 
uterine function becomes deranged, the constitutional disease is so 
far advanced as to be easily recognized. One is greatly aided in 
diagnosis when the menses have for a time been regular, but become 
deranged without any disease of the sexual organs being present. 

When amenorrhoea occurs as the result of some constitutional 
disease that is incurable, the special interest of the gynecologist ends 
when the diagnosis is made, because no special treatment is of any 
avail. On the other hand, in menorrhagia, when due to chronic 
affections of the heart, liver, or kidneys, something may be accom- 
plished in the way of modifying the trouble, and thereby prolonging 
the life of the patient. Here also the management is general, not 
special, and hence does not come within the scope of the present 
work. 

Prematiire Menstruation from Deranged Conditions of Life and 
Deranged Innervation. — The rule that the menses should appear after 
the completion of development which occurs at puberty is violated in 
the cases now under discussion, because the uterine function is taken 
up before the general development is completed. In determining 
the question of premature menstruation it is necessary to ascertain 
whether the patient is sufficiently mature in development to render 



48 DISEASES OF WOMEN. 

her capable of taking up this uterine function. She may be old 
enough, but not developed enough in her general system. The 
causes of this too early appearance of the menses are various. It 
seems that opposite conditions of life produce the same results. Bad 
air, poor food, overwork, and impure social surroundings, have this 
ill effect ; at least, cases frequently occur among those who are so 
poor that they fail to obtain all that is necessary to health. 

This fact regarding the premature activity of the sexual system 
appears to arise from a law in Nature, which is that all plants and 
animals placed in unfavorable environments devote more of their 
energies to reproduction than those that are more favorably situated. 
It would appear as if they appreciated their danger of being crowded 
out of existence, and hence struggle more vigorously to procreate. 
Yiewing the subject in this light it may be said, to speak figurative- 
ly, that girls and plants while stunted by hving in poor soil run to 
seed. 

The same premature menstruation occasionally occurs among 
those who are favorably situated in regard to the necessities of animal 
life. Those who have the means of supplying all their wants, real 
or imaginary, and lack intelligence and culture, which would enable 
them to profitably occupy their minds, suffer like the poor. This 
would indicate that the real cause of the sexual precocity was 
derauged innervation. 

Delay of the advent of menstruation occurs among those who 
are situated apparently like those just described. The girl w^ho 
labors out-of-doors and develops great muscular strength may fail to 
menstruate until past the usual age. So, also, the same thing occurs 
to some who live in luxury. In such cases the cause is, no doubt, 
imperfect innervation. In the class first described attention is given 
to the genital system prematurely, while in the second class the 
social element of life is neglected. 

The general management of these patients consists in removing 
the cause, if possible, by placing them in such healthful surround- 
ings as will prevent the evil. This, however, is not alwaj^s in the 
power of the physician, and he has to meet the wants of those really 
in suffering. When the menstrual function has been established, 
though prematurely, no effort should be made to stop it. Attention 
should be given wholly to building up the general system. The 
overworked should obtain rest and good food. The nervous system 
should have attention. The perverted mind-action should be cor- 
rected by wholesome brain-occupation. The indolent should be 
stimulated to greater activity. Society is desirable for those in 



ARREST OF DEVELOPMENT. 49 

wbom the menses are delayed, and quiet conntry life should be pre- 
scribed for those who have suffered from premature social excite- 
ment. 

ILLUSTRATIVE CASES. 

Premature Menstruation from Deranged Innervation, produced by 
Luxurious Surroundings and Over-Stimulation of the Nervous System. 

— The patient was an only daughter of wealthy parents, and was al- 
ways a bright child and greatly indulged by her family and friends. 
She was treated at home and at school more like a young lady than 
a child, and was almost constantly in company. In the parlor and 
drawing-room she associated with her elders, and was devoted to the 
opera and theatre from the time she was big enough to visit such 
places of amusement. She often suffered from headaches and indi- 
gestion, and was always excitable mentally, and at times peevish 
and irritable. She menstruated first at eleven years quite freely, 
and the How lasted four days. At this time she had all the ap- 
pearances of girlhood. The mammary glands were slightly de- 
veloped, but her form had not attained anything like maturity. 
From this time onward she menstruated regularly and normally. 
She was first seen during her first menstrual period, and then her 
parents were advised to change all her habits of life. She was taken 
to a quiet country home in summer, instead of a fashionable hotel 
at which she had previously passed her summers, and permitted to 
spend her time in the fields with her attendant, who was a woman 
of good common sense and experienced in the proper care of chil- 
dren. All excitement was kept from her, and her habits of life 
made regular and natural. In winter she was permitted to attend 
school for half the time, and the rest of the day was devoted to draw- 
ing, reading, and gymnastic exercises. Abundance of sleep in the 
early part of the night was directed, and cold bathing every morn- 
ing, No medicine was given. Under this general management she 
grew in size quite rapidly, and by the time she was sixteen years old 
she was a well-developed young lady, and enjoyed very good health. 
Premature Menstruation occurring in a Poor, Ill-cared-for Girl, 
from the Lowest Grade of Society. — This patient, a hospital one, was 
ten years and five months old when she first menstruated. She li^ed 
in one of the poorest tenement regions of the city. Her father was 
a drunkard, and left his family to the care of the mother, who was 
a washer-woman. This girl lived by begging while very small, and 
when older worked in a tobacco-factory. She was tliirteen years old 
when seen in the hospital, and had menstruated regularly from the 
age mentioned. Her general health was poor, very poor; she had 
5 



50 DISEASES OE WOME>^. 

the appearance of an undersized, ill-fed, undeveloped girl, quite 
ignorant, and doubtless of low moral nature. She was in the hospi- 
tal to be treated for specific vaginitis. 

Delayed Menstruation in a Girl who was large, strong, and in good 
health. — The daughter of a poor farmer had spent most of her life 
in doing out-door farm- work. Her food was milk, oatmeal, and 
potatoes. She was large, muscular, and full-blooded. Between six- 
teen and seventeen years of age she developed the characteiistics of 
womanhood, but at the age of seventeen years and six months the 
menses had not appeared. She was then siiifering from occasional 
headaches, backache, drowsiness, constipation, and general indisposi- 
tion. These symptoms, with delay in the appearance of the menses, 
caused her to seek advice. She was very muscular and fine-featured. 
The pulse was full and strong, the mammary glands well developed, 
and her figure was markedly of the female t\^e. A teaspoon ful of 
sulphate of magnesia and half a teaspoonful of table-salt in a goblet- 
ful of water were ordered every morning an hour before breakfast. 
The liberal use of animal food was directed. She was advised to 
take a vacation from her hard labor on the farm, and visit her rela- 
tions who were more comfortably situated. These directions were 
followed out for a month, with no effect, except to relieve her con- 
stipation. The saline mixture was stopped and the following or- 
dered: Quinige sulph., 3i; ext. belladonnge, gr. ij ; ext. aloes aq., 
gr. iv. Pil. no. xx : one before each meal. When the headache and 
general feelings of malaise returned, I prescribed spiritus ammon. 
arom., ^ss; aquae camph., 5 ijss — a dessertspoonful every three 
hours. At the end of two months, she began to menstruate. 
There was considerable pain accompanying the flow, which was 
rather dark in color. The pills were continued, but she was soon 
able to give up one a day, and then two, and finally cease taking 
them altogether. At each period, which recurred regularly, she took 
the ammonia and camphor mixture. Six months after her first men- 
struation she reported that she was regular and quite well. 

Delayed Menstruation in a Patient of Marked Phlegmatic Tem- 
perament and Indolent Habits. — The daughter of wealthy parents, of 
average height but quite stout, and presenting all the evidences of 
the phlegmatic temperament, was brought to me at the age of six- 
teen, because she had not menstruated. I learned that she lived 
well, slept much, and took but little exercise, mental or physical. 
She had all the appearance of having arrived at puberty, and for one 
year had had a shght leucorrhoea, but no menstrual flow. She was 
ordered to take lessons in horseback-riding, and to walk for half an 



ARREST OF DEVELOPMEiTT. 51 

hour twice a day. A Turkish bath with thorough massage three 
times a week was also directed ; I prescribed potass, permanganat., gr. 
XXX, in pil. no. xxx : one three times a day, before meals. This 
treatment was contiiiued for about three months, excepting that at 
the end of one month the pills were omitted for three weeks and 
again taken up, and continued until the end of the three months. 
At this time she menstruated, and continued to do so regularly after- 
ward. The flow was never very free, but it continued about five 
days each time. 

Irregular Menstruation from Deranged Innervation and Anaemia. — 
This patient was twenty-five years of age, of sanguine, nervous tem- 
perament, and had been in good health up to the time that she 
was nineteen. She menstruated first at fifteen, and continued to 
do so regularly, until the year that she graduated in school, when 
nineteen years old. During the latter half of her last year in 
school her menses became irregular, six weeks or two months in- 
tervening between the periods. At this time her health became 
much reduced, but after leaving school she improved generally, and 
the menses became regular. At twenty four years of age she began to 
indulge to excess her love for music and painting, which had always 
been favorite studies with her. Dyspepsia and general debility fol- 
lowed, and the menses became again irregular. She first came under 
my care at twenty-five, and at that time the menses had been absent 
for three months. She was quite anaemic, and her nervous system 
much exhausted. She was ordered to give up her favorite studies, 
and devote herself to regaining her lost health. She was directed to 
take three regular meals a day, and in the forenoon a cup of beef- 
tea or a glass of milk, and in the afternoon extract of malt, or else 
peptonized milk and a glass of claret. Before her regular meals she 
was given tr. nucis vom.. Til iij ; vini ipecac, tt| ij, in a wine-glass 
of warm water. This improved her appetite. After meals she 
took a teaspoonful of the following: Tr. ferri chlor., 3 ii j ; Hq. ar- 
senic, hydrochlor., 3 j ; spiritus limonis, 3 ss ; syr. simp., 5 j ; aquae 
font., 5 ij. This treatment was continued for three weeks, with the 
effect of improving her general condition, but the menses did not 
return. In place of the iron-mixture she was given the permangan- 
ate of potash pills, but without any apparent efl:ect. Iron was again 
given, and the menses returned after she had been six weeks under 
treatment. She continued to be irregular, some five and six weeks 
between the periods, but, as her genei-al health improved, the inter- 
menstrual periods became shorter, until the normal time was estab- 
lished. Altogether she was under observation for one year, and 



52 DISEASES OF WOMEN. 

during most of that time she took tonics containing some form of 
iron. Citrate of iron and quinine, iodide of iron and whisky, po- 
tassio-tartrate of iron and wine, were the chief preparations given. 

Suppression of the Menses from Acute Derangement of Innervation. 
— A lady, twenty-one years of age, of excellent physique, who had 
menstruated with great regalarity from the time that she was fifteen 
years of age, left home for the first time in her life to visit some 
friends in a far-distant city. On the day that her menses should 
have appeared, she was alone and not accustomed to traveling, and 
she became much excited over her journey, and was greatly fatigued 
when she reached her friends. She could not sleep on the cars, and 
her appetite left her almost altogether. I was called to her on the 
third day after she left home, and a few hours after her arrival. 
The menses had not appeared ; her head ached very acutely ; her face 
was flushed ; skin dry and pulse excited. The temperature was 
100° Fahr. I ordered a hot foot-bath and the forehead bathed with 
alcohol, and prescribed ammon. bromid., gr. xv, tinct. aconit. rad., ni 
ij, every three hours in a small glass of Yichy water. She was kept 
quiet in bed. After taking three doses of the medicine, she slept 
fairly well during the night. Next morning her headache was 
almost gone ; her pulse was quiet ; flushing of the face less notice- 
able, and she had an appetite, but the menses had not come. I pre- 
scribed camph., gr. v ; ext. lupul., gr. x ; ext. valerian, gr., x : in cap- 
sul. 'No. X. One to be given every three hours during the day and 
following night if awake. She slept well in the night and next 
morning began to menstruate. 

Amenorrhoea from Chronic Derangements of Innervation. — This 
patient was twenty-four years of age, of good constitution, and had 
menstruated normally until six months before the taking of this his- 
tory. In that time she lost her mother, to whom she was greatly 
devoted. This prostrated her with grief, and about the same time 
her father suffered reverses in business, so that my patient, who had 
up to this time lived in luxury, was obliged to seek employment to 
support herself. From the death of her mother she failed to men- 
struate until nine months afterward. She was greatly depressed up 
to the time that she began treatment, and, although her general 
health was good, she was melancholy, and was greatly annoyed by 
her new occupation and changed social position. The amenorrhoea 
was a great source of anxiety to her, because some of her friends 
had told her that it was sure to lead to consumption. I fully assured 
her that she was in no danger, and that her recovery was certain. 
This alone was a decided tonic. 



ARREST OF DEVELOPMENT. 53 

I ordered the following : Strjclinise siilphatis, gr. ss ; tr. cannabis 
Indie, 3 ij ; tr. card, comp., 5 j ; aquae font., § ij. Teaspoonful be- 
fore meals. This she continued for two weeks. I then ordered 
Parrish's compound sirup of phosphates, a teaspoonful, after meals; 
in water. This was taken regularly for three weeks, when the fol- 
lowing was given instead: Quin. sulph., 3ij; ext. valerian., 3j; 
ext. cannabis Indic, gr. v : in capsul. No. xxi. One before meals, 
and a glass of red wine after meals. This was continued for over a 
month. During this time she was induced to take more out-of-door 
exercise, and divert her mind by light amusements. General gym- 
nastic exercise was taken, but not systematically nor regularly. When 
this course of treatment had been employed she menstruated, and 
from this time on was regular and well. In general spirits she 
began to improve considerably before the menses returned, but after- 
ward her progress was rapid, and recovery complete. This case will 
suffice to illustrate this cause of amenorrhoea. 

Imperforate Hymen causing Non-appearance of the Menstrual Flow. 
— This affection should be classed with atresia of the vagina, but is 
given here because the history of such cases resembles delayed men- 
struation from some of the causes just given. This condition is 
usually unnoticed until puberty, when all the evidences of menstrua- 
tion appear except the flow, which is arrested by the imperforate, 
thickened hymen. The fluid which accumulates at each menstrual 
period distends the vagina first and then the uterus, the distention 
increasing at each period. Pelvic tenesmus, a feeling of distention 
of the vagina, and enlargement of the abdomen are the chief symp- 
toms and signs presented. 

In course of several months the suffering causes the patient to 
seek relief, when a diagnosis can be made by physical examination. 
The treatment is to evacuate the fluid by opening through the hymen. 
This is attended with great danger, owing to the tendency to inflam- 
mation and septicaemia. The fluid is dark, thick, and tarry in char- 
acter, and decomposes quickly on exposure to air. This and the 
irritation of the vagina and uterus may account for the tendency to 
inflammation and blood-poisoning. The method of treatment found, 
in past times, to be the safest was to make a small opening, evacuate 
very slowly, and subsequently enlarge the opening, or exsect the 
hymen entirely. Another method is to make a free incision with 
the incandescent knife of a thermo-cautery, evacuate rapidly, and 
wash out the uterus and vagina. This method has proved to be 
safer since the days of antiseptic surgery, and may be adopted. 



CHAPTEK lY. 

FLEXIONS OF THE UTERUS. 

I CONSIDER flexion of the uterus as a deformity, and it certain- 
ly belongs to that order of pathological conditions. The pathol- 
ogy, cause, symptoms, physical signs, and treatment of flexion, all 
differ from version, hence a clear distinction between the two should 
be made in order to avoid confusion. 

Anteflexion of the uterus is most frequently a congenital deform- 
ity, some arrest or derangement of development giving rise to the 
malformation. Occasionally it results from disease, inflammatory 
or degenerative, which weakens the uterus at a certain point and 
permits it to become bent upon itself. I shall limit myself to the 
consideration of flexion occurring as the result of these two causes, 
and shall purposely omit all deformities caused by pre-existing affec- 
tions, such as adhesions of the uterine body to other pelvic organs, 
tumors in the walls of the uterus which by their weight bend the 
uterus, and pressure of abdominal tumors which crowd the uterine 
body to either side. Whenever flexion is produced by some such 
antecedent disease, I prefer to consider it as a complication of the 
primary affection, rather than to discuss it as a distinct condition. 

The point of flexion is at the junction of the body and cervix. 
It may occur above or below that point, but only as a very unim- 
portant exception to the rule. The several forms of flexion I have 
denominated flrst, second, and third. The first is flexion of the 
body ; the second, flexion of the cervix ; and the third, flexion of 
both body and cervix. 

Taking the ground that flexion is a deformity, it may naturally 
be attributed to some defect of development ; and in order to un- 
derstand the lesions of form and structure arising from arrest or 
derangement of development, it becomes necessary to restate the 
essential points in that process as relates to the uterus. 

At birth the uterus and vagina are joined in such a manner that 



FLEXIONS OF THE UTERUS. 55 

the cervix uteri projects into the vagina but a very short distance, 
and about equally on the anterior and posterior walls of the vagina. 
After birth the uterus remains without change until puberty, ex- 
cept during the time of second dentition, when the palma plicata 
disappears from the body of the organ, with the exception of one 
fold which runs lengthwise. The body increases a little in size, so 
that the body and cervix become more nearly equal. At the same 
time the organ settles down into the pelvic cavity, and the cervix 
elongates and becomes more prominent in the vagina. 

At puberty the uterus undergoes secondary development. The 
organ increases in size, this being especially true of the body. Un- 
til puberty the uterus differs but little in shape from that of the 
new-born babe, which has been already described ; but at the time 
when menstruation or functional activity of the reproductive organs 
is about to be established, it assumes the form and structure of the 
mature organ. Suffice it to say that, as the tissues are developed, 
they become denser, giving to the organ the firmness necessary to 
support it and keep it from bending in any direction by its own 
weight. 

There are two anatomical points bearing upon the subject now 
under consideration to which I desire to call particular attention : 

1. The position or relations of the uterus to other pelvic organs 
at birth, during girlhood, and after puberty. 

2. The relations of the cervix uteri and the vagina at the com- 
pletion of primary formation and after secondary development. 

The infantile pelvis is relatively narrower, deeper, and less curved 
than the adult ; hence the canal formed by the uterus and vagina is 
straighter than after puberty. The small size of the infantile uterus, 
the thinness of its walls, and flaccid condition of its tissues, render it 
capable of bending forward or backward according to circumstances. 
This fact may account for the variety of opinions regarding the 
position of the uterus previous to puberty. At birth the uterus is 
high up in the pelvis, but settles down during the second dentition, 
as has been already stated, and forms with the vagina the arc of a 
smaller circle, having its concavity forward; hence the greater 
liability of the uterus to be anteflexed or ante verted during girl- 
hood, if it deviates at all ; but, according to Klob, the uterus is 
neither bent forward nor backward until puberty. 

From the information obtained by the study of embryology and 
the anatomy of the reproductive organs, one must necessarily con- 
sider the uterus and vagina as forming one canal. The peculiar ar- 
rangement at the junction of these organs appears as if forinod from 



56 DISEASES OF WOMEN. 

an invagination, the upper part of the vagina receiving the dupli- 
cation of the uterus which forms the vaginal portion of the cervix. 
This invagination is very slight at birth, as may be seen by referring 
to any normal infantile uterus. The projecting portion of the cervix 
at this period is about equal, anteriorly and posteriorly. During 
the period of second dentition, when the uterus settles down, this 
portion of the cervix becomes more apparent still. It will also be 
observed that the posterior wall of the cervix projects a little farther 
than the anterior. At puberty, when the sexual organs undergo 
secondary development, invagination progresses still further, and the 
cervix and vagina assume the relation of adult maturity. It should 
be noted that the portion of the cervix which projects into the 
vagina is much longer posteriorly than anteriorly. This must neces- 
sarily be so, to some extent, from the fact that the uterus and vagina 
form an arc of a circle corresponding to the curve of the pelvis ; but 
the difference is slightly greater than is necessary to make the curve 
form part of a circle. Perhaps it would be more correct to say that 
the junction of the cervix and vagina forms an obtuse angle. 

I am thus particular in describing these relations of the uterus 
and vagina, because I hope to show hereafter that arrest or derange- 
ment of the process of invagination of the cervix uteri has much to 
do in causing flexion. 

Anteflexion of the Uterus. — I prefer to consider anteflexion of 
the uterus a deformity, although it is usually called a displacement, 
because it certainly is a lesion of form rather than position. 

The pathology, cause, symptoms, physical signs, and treatment of 
flexion all differ from those of displacements of the uterus, hence 
the clearer that the distinction between the two can be made the 
better. 

The deformities which occur at puberty are perhaps more fre- 
quently lesions of size or quantity from arrest of growth than 
lesions of form from arrest of development. During secondary 
development the infantile uterus is transformed into that of the 
adult chiefly by the increase in the size of the body and fundus, 
and the dipping down of the cervix into the vagina. When these 
changes do not take place properly, especially if the invagination 
of the cervix is arrested, the uterus becomes flexed upon itself. 
Other causes of this malformation there are which will be again re- 
ferred to. 

Anteflexion of the uterus is usually a congenital deformity, 
caused by arrest of development occurring during the later stages 
of that process. It is inferred from the clinical history of flexion 



FLEXIONS OF THE UTERUS. 



57 



that it is congenital, but this is not perhaps strictly true of all the 
cases that occur as primary lesions. I presume that most frequently 
the malformation takes place during secondary development at 
puberty. Occasionally it comes from some pre-existing disease, in- 
flammatory or degenerative, which weakens the walls of the uterus 
at the junction of the body and cervix and permits it to become 
bent upon itself. Retroflexion often, perhaps generally, is devel- 
oped from retroversion, the one holding a causative relation to the 
other, but this form of acquired flexion will most conveniently 
come under the head of retroversion and its complications. 

Clinically considered in relation to causation there are two classes : 
the congenital, called so because it is usually first recognized at pu- 
berty ; and acquired, because it generally appears after puberty and 
follows some previous uterine disease either inflammatory, or a mal- 
nutrition which reduces the quantity of tissue at a given point, and 
permits the uterus to bend upon itseK. Flexions from these two 
causes constitute a class by themselves, and therefore they alone 
will be treated of in this connection. Flexions occur in connection 
with other aft'ections, such as adhesions of the body of the uterus to 
other pelvic organs ; tumors in the walls of the uterus, which, by 
their weight, bend the uterus upon itself ; and pressure from ab- 
dominal tumors which crowd the uterine body out of place ; but 
flexion in such cases is only a complication of the aftection which 
causes it, and does not belong 



to the subject of flexion as a 
primary lesion. Theoretically, 
the uterus might become 
flexed in either direction; 
but practically the forward 
and backward, anteflexion and 
retroflexion, are the only two 
forms that occur as uncom- 
plicated affections. The later- 
al flexions are, as a rule, sec- 
ondary to the diseases already 
mentioned. 

Anteflexion, which occurs 
as the result of imperfect de- 
velopment, and which is oc- 
casionally acquired from mal- 
nutrition, is by far the most common. There are three varie- 
ties of anteflexion : First, forward flexion of the cervix (Fig. iU^i ; 




Fig. 34a. — First variety 
cervix. 



autotiexiou of 



58 



DISEASES OF WOMEN. 




Fig. 35. — Second variety; anteflexion of body 
of uterus. 



second, forward flexion of tlie body (Fig. 35) ; and, third, for- 
ward flexion of both body and cervix (Fig. 36). 

Pathology. — Flexion of 
1 any form necessitates some 
defect in the structure - of 
the uterus. This constitutes 
one of the essential difl'er- 
ences between flexion and 
version, which latter is sim- 
ply an error of location 
without, necessarily, any 
change of structure of the 
uterus. The flexion is usu- 
ally at the junction of the 
body and cervix, the point 
corresponding to the inter- 
nal OS. Flexion at any point 
in the body or cervix oc- 
curs only as an exception, 
which need not be noticed here. At the point of flexion the 
tissues of the uterine walls are deficient. On the side to which 
the organ is bent the wall is compressed and attenuated. On 
the other side the loss of tissue is not so marked, the thickness 
being but slightly diminished 
by the stretching. The sub- 
mucous, fibrous stratum of 
tissue, which is said to give 
firmness and support to the 
organ, is absent or deficient on 
the side to which the uterus is 
bent. 

The effect of flexion on the 
uterine canal is to produce 
constriction or occlusion of 
the internal os. The external 
OS is sometimes more open 
than in health, owing to trac- 
tion being made on the pos- 
terior lip. The stricture thus 
gives rise to accmnu- 




FlG. 



— Third variety ; anteflexion of body 
and cervix. 

formed gives rise 

lation of the secretions of the uterine cavity, and to partial retention 

of the menstrual products. The circulation in the uterus, as will be 



FLEXION'S OF THE UTERUS. 59 

readily understood, is interfered with. The obstruction tends to keep 
up congestion, and this may eventually lead to oedema and a predis- 
position to endometritis and pelvic peritonitis. 

From all these causes derangement of function follows. The men- 
strual fluid, in place of escaping passively, is expelled, perhaps, by 
spasmodic contractions, attended with colicky pain. In other words, 
there is dysmenorrhoea. Sterility also exists in the majority of cases. 
These pathological conditions increase with time. The pressure at 
the point of flexion produces anaemia and atrophy of that part, and 
the intrinsic support of the uterus being thus diminished the flexion 
increases. Hence, the flexion of the first variety often progresses to 
the second and third. 

The anatomical appearances in flexion are well described in ^N^ie- 
meyer's " Text-Book of Practical Medicine." I quote that portion 
which applies to anteflexion of the body of the uterus : " On autopsy, 
flexion of the uterus may be readily recognized, as part of the pos- 
terior wall of the body, instead of the fundus, forms the highest part 
of the uterus. Generally, we may restore the sunken fundus to its 
position, but it sinks back again to its former place when we let go 
of it. If we cut the uterus out of the body, and hold it erect by the 
vaginal portion, the fundus sinks down anteriorly ; if it be held 
horizontally, it not infrequently holds its weight if the flexed side 
be upward, but it bends together if we reverse it." To this I would 
add that in the first variety the cervix projects into the vagina much 
farther on the posterior wall than on the anterior ; indeed, in marked 
cases, the anterior lip of the cervix uteri is very little below a line 
corresponding to the point of union between the cervix and the an- 
terior vaginal wall. 

Natural History of Anteflexion. — SyTnptomatology. — Derangement 
of uterine function constitutes the principal point in the natural his- 
tory of fiexion. Menstruation, from its first establishment, is often 
painful — there is dysmenorrhoea. The severity of the pain bears 
some relation to the extent of flexion. The greater the deformity 
the more marked is the pain, though there are exceptions to this rule. 
The character of the pain is of the greatest importance. It is inter- 
mittent, and always precedes the flow. When the flow begins, the 
pain either subsides or becomes much less. The pain closely resem- 
bles that which occurs in abortion in the early months of pregnancy. 
The reason, I presume, is that while the fluid is accumulating in the 
uterine cavity, pain is excited by distention ; but the flow Avhen 
once started, continues with less expulsive eflort. Painful men- 
struation often occurs without flexion, but in such cases the pain 



60 DISEASES OF WOMEX. 

continues throughout the whole period, or during the early part of 
it, and is not relieved by dilatation of the cervix ; while in flexion 
it precedes the flow, and is relieved temporarily by dilatation. This 
pain, at the commencement of menstruation, is the most prominent 
symptom in the history of flexion as it occurs in the young girl. The 
trouble tends to increase gradually. If the patient gets married, all 
the symptoms usually increase. Should she become pregnant, there 
is great liability to miscarriage during the early months. The effect 
of the pregnancy, however, in part at least, is to remove the deform- 
ity, even when miscarriage occurs, so that pregnancy is likely to occur 
again, and go on to full time, and the deformity is cured completely. 
Checking the menses by exposure to cold, or any cause which will 
produce hypersemia of the uterus, or endometritis, promptly increases 
the dysmenorrhoea, and gives rise to new symptoms. Leucorrhoea, 
backache, local tenderness, deranged digestion, and nervous disturb- 
ances, are all added to the original symptoms. Sometimes in ante- 
flexion frequent micturition is a marked symptom. 

There are all varieties and degrees of prominence of the symp- 
toms in the natural history of flexion. The dysmenorrhoea which 
begins at puberty may continue, and increase but little through life. 
This is most likely to be the case if the individual remains unmar- 
ried, and can avoid all the conditions which tend to aggravate uter- 
ine disease. On the other hand, the dysmenorrhoea may increase in 
severity during each succeeding menstruation, and after marriage 
become intolerable. In the intervals between the menstrual periods 
the patient in her early life is free from trouble, but eventually 
symptoms of uterine and vaginal inflammation are manifested. 
Constitutional derangements, especially of the nervous system, fol- 
low, and in time we have the broken-down, miserable patients, famil 
iar to all practitioners. Such patients often seek relief in the use of 
stimulants and opium, which only soothe for a time, but eventually 
aid in undermining the health and strength of the unfortunate suf- 
ferers. 

The subjects of flexion are very liable to pelvic peritonitis and 
diseases of the ovaries and Fallopian tubes, with all the suffering 
wliich these affections give rise to. 

Physical Signs. — Although the history alone might lead one 
with a tolerable degree of certainty to suspect the presence of flex- 
ion, the physical signs must be depended upon for an accurate diag- 
nosis. The physical signs of flexion arise from the changed relations 
of the body and cervix to each other. These signs are detected by 
the touch and the uterine probe. The touch may indicate that the 



FLEXIONS OF THE UTERUS. 61 

cervix occupies its normal position, or it may be found to be retro- 
verted, which is its most frequent position in anteflexion. The os 
points toward the introitus in the same way that we find it in retro- 
version. The vaginal portion of the anterior wall of the cervix is 
much shorter than the posterior. Carrying the finger along the an- 
terior vaginal wall, the body of the uterus can nsually be felt bend- 
ing forward. The bimanual examination reveals the deformed 
condition of the uterus in lean patients, whose abdominal parietes 
are yielding ; but in fleshy subjects with rigid abdominal muscles, 
very little can be learned by this mode of exploration. When 
rigidity of the parts is the obstacle to exploration, an anaesthetic 
may be used with great advantage, as practiced by Sir J. Y. Simpson. 

When the signs thus obtained point to flexion, the diagnosis 
should be confirmed by using the sound. Much trouble is often 
experienced in introducing this instrument. Indeed, it is impos- 
sible in extreme flexion to carry the sound into the uterus without 
first straightening the bend at the junction of the body and cervix. 
To do this, the cervix should be seized by a tenaculum, and gently 
drawn downward, while at the same time the fundus is pressed up- 
ward and backward. In this way the canal is partially straightened, 
and the sound can be introduced. There are cases where it is only 
necessary to curve the sound properly and manipulate with care, 
and the point of flexion can readily be passed. When the sound 
passes into the body of the uterus in the direction indicated by the 
touch, the diagnosis is complete. While there are many conditions 
which might present the signs of flexion as obtained by the touch, 
the combined testimony of the touch and sound are sufficient to 
make the diagnosis sure. 

Causation. — There are several causes of flexion, which may ac- 
count for the diflerent opinions held by authors on this subject. 
The errors, I presume, come from investigators accepting the cause 
found in a limited number of instances as applying to all cases of 
flexion. Some of the more important causes assigned may be briefly 
noticed. 

Rokitansky considered that the peculiar density and arrange- 
ment of the mucous membrane of the cervix and lower part of tlie 
corpus uteri, formed one of the chief supports of the organ, and gave 
it its slight anterior inclination ; consequently, he looked upon the 
pathological state of this layer as the basis in the development of 
uterine flexions. He thought the uterus bent upon itself, from cir- 
cumscribed atrophy of one of its walls, arising from inflammation. 
He claimed that the glands of the mucous membrane, becoming dis- 



62 DISEASES OF WOMEN". 

tended from imprisoned secretions, so pressed upon tlie other tissues 
as to cause atrophy at that part. When the distended glands rupt- 
ured and collapsed, the part rendered thus defective permitted the 
uterus to bend upon itself. Several eminent writers on this subject, 
Dr. Ludwig Joseph being the most recent, after careful observa- 
tions, have been unable to discover this peculiar condition of the 
mucous membrane and its submucous layer to which Eokitansky 
alludes. If they are correct, further discussion of this supposed 
cause is useless. Should Rokitansky be right, the cause he favors 
would chiefly aifect cases of acquired flexion ; while the majority of 
cases occur before we have any evidence that inflammation pre- 
ceded it. 

Yirchow attributes the primary cause of flexion to congenital 
shortness of the anterior uterine ligaments, which drag the body of 
the uterus forward, or flex it. The uterus, being held in this posi- 
tion, pressure results, which leads to atrophy of the tissues, and thus 
all the conditions of flexion are present. 

Klob, who is one of the best authorities on uterine pathology, 
doubts the views expressed by Yirchow, and states that with the nor- 
mal flrmness of the tissues the uterus is not likely to be deflected by 
the cause in question. He also calls attention, as a reason against the 
theory of Yirchow, to the fact that false membranes or short liga- 
ments, which would incline and fix the fundus forward, would ne- 
cessarily cause pressure on the fundus of the bladder. This would 
cause the bladder to distend more in its lowest portion, which would 
press the lower part of the cervix uteri backward, and in place of 
producing flexion would cause anteversion. Klob admits that the 
cause assigned by Yirchow may produce or maintain flexion, but 
only w^hen there is defect of tissue in the uterus itself, arising from 
some anterior cause. 

The relation of the bladder to the uterus is looked on by some 
winters, including Yirchow and Ludwig Joseph, as of some impor- 
tance in the etiology of flexion. The uterus is known to make a 
descent corresponding to the variations in the shape of the bladder, 
which in foetal and infant life changes from the elongated fusiform 
to the short ovoid shape, and its fundus, thus approaching the floor 
of the pelvis, draws the attached uterus with it. As the cervix 
uteri is closely attached to the posterior surface of the bladder, it 
w^ill be readily understood that perverted development in the con- 
nections of the two organs might lead to flexion. 

The only causes which I consider worthy of discussion in con- 
nection with anteflexion, when it occurs as a primary or uncompli- 



FLEXIONS OF THE UTERUS. 63 

cated disease, are : 1. Malformation resulting from arrested or im- 
perfect development. Flexion arising from this cause may be classed 
among the congenital deformities. 2. Deformities arising from in- 
flammation and degeneration of the uterine walls on one side. This 
will include atrophy of the anterior uterine wall at the os internum 
from inflammation and distention of the cervical glands ; also fatty 
degeneration in advanced life, and excessive involution after parturi- 
tion, by w^hich one of the uterine walls is weakened at the junction 
of the cervix and body. These may be called acquired flexions. 

I purposely omit a number of conditions usually given as causes 
of flexions, such as metritis, enlargement of the corpus uteri, preg- 
nancy, uterine tumors, abdominal tumors, accumulations of fluid in 
utero^ ascites, fecal accumulations, and adhesions from inflammatory 
exudations. Several of these causes, such as pregnancy, produce 
flexion so very seldom that they may be treated as exceptions to the 
ordinary laws of pathology, and are of no practical importance. The 
others named are more important than the flexions which they pro- 
duce, and I should prefer to discuss flexion occuriing under such 
circumstances as a complication of the primary affection. It is, to 
say the least of it, objectionable classification, to discuss the primary 
and most important disease as the cause of a consecutive affection, 
and one which does not always follow. 

Regarding the first cause — imperfect development — I can readily 
see how flexion might occur therefrom. During the time when in- 
vagination of the lower portion of the cervix and upper part of the 
vagina takes place, the process is liable to progress farther on one 
side than on the other. Should the posterior vaginal wall become 
reflected much higher than the anterior, the attachment of the vagi- 
na, being lower on the anterior surface of the cervix, would naturally 
pull it forward. From the fact that this malformation at the junc- 
tion of the uterus and vagina is present in the vast majority of cases 
of anteflexion of the cervix, I have looked upon it as one important 
cause. If this arrangement should tend, as it probably does, to bring 
the cervix forward so as to flex the uterus to a slight degree previ- 
ous to its complete development, the pressure at the point of flex- 
ion would arrest the growth at that point, and then the wall would 
become more attenuated still, and flexion of the body would be 
produced. 

Imperfect development may cause flexion in another way. 
The infantile uterus, having little strength of tissue to support itself, 
might readily become flexed, and so remain during the period of 
secondary development. I am aware that good authorities, such*as 



64 DISEASES OF WOMEN. 

Klob, state that previous to puberty the uterus is neither bent back- 
ward nor forward ; but other observers have found the infantile 
uterus anteflexed in many cases, and one can readily understand why 
the organ might remain so. The position in sitting at school and in 
sewing so often maintained by girls, constipation, and improper cloth- 
ing, all tend to retard development and hence produce flexion. The 
uterus might readily increase in size at all parts except the portion 
compressed at the point of flexion. 

Flexion occurs also from excessive development of the cervix. 
The unnaturally long cervix pressing upon the posterior wall of the 
vagina is inclined forward, while the body of the uterus remains in 
its normal axis. This produces slight flexion, which in time becomes 
greater, on the principle that the deformity, once established, tends 
to increase. 

When flexion is caused by inflammation, the explanation given 
by Rokitansky and already referred to, applies in some cases of ac- 
quired flexion. Irregular involution is doubtless one of the causes of 
flexion when it occurs after confinement or miscarriage. If press- 
ure was brought to bear on the cervix, fundus, or both, so as to favor 
flexion, involution might go on beyond the normal limits at the 
point of pressure. 

Treatment. — A brief review of the various plans of treatment 
will, I believe, show that while they are of great value, and capable 
of giving relief in many cases, still it will be found that they do not 
fully equal all demands. The use of extra-uterine pessaries will re- 
lieve some of the prominent symptoms, but will not overcome the 
deformity. Intra-uterine pessaries, while they sustain the uterus in 
its normal shape, are objectionable in some respects ; they are often 
difiicult to introduce, are not easily held in position, and are liable 
in some cases to cause so much irritation as to make their prolonged 
use dangerous to life. 

The surgical methods which have for their object only to relieve 
the symptoms or evil consequences of flexion, are chiefly dilatation 
and division of one wall of the cervix. Dilatation is certainly of 
much value, but the improvement is often, indeed generally, only 
temporary. Division of one of the cervical walls answers the same 
purpose as dilatation, and the effect is not more lasting. But neither 
of these modes of treatment overcomes the deformity altogether, and 
seldom permanently cures the troublesome symptoms. The merit 
of dividing the cervical wall appears to me to be, that it may correct 
the conditions of the flexion which cause sterility, and when that is 
accomplished, and pregnancy follows, the development of the uterus 



FLEXIONS OF THE UTERUS. 65 

during gestation permanently cures the malformation as a rule. If 
pregnancy does not follow, the patient is not always improved, ex- 
cept temporarily, by the treatment. 

The objects to be attained in the treatment of flexions of the 
uterus are, to straighten the organ and to keep it so until the defect- 
ive portions of its walls become developed sufiiciently to render it 
self-sustaining. Should the means used fail to overcome the de- 
formity, the next aim should be to relieve the patient from the con- 
sequences of the flexion by other means, such as dilating the canal of 
the uterus, or dividing the posterior wall of the cervdx after the 
manner of Sims. The means to be used in the management of 
flexion must be adapted to each case, and hence the subject resolves 
itself into, first, the treatment of flexion of the cervix ; second, flexion 
of the body of the uterus ; and, third, flexion of both. 

It follows, naturally, that the treatment of flexion of both the 
body and cervix — i. e., the third form mentioned — should include the 
treatment of the first and second forms. 

The treatment of flexion is as follows: When the vaginal por- 
tion of the cervix is unusually long and conical, amputation may be 
called for, and is often followed by very satisfactory results. In the 
majority of cases a less important operation will answer, ^j clip- 
ping out a Y-shaped piece in each lateral edge of the os, and extend- 
ing upward from an eighth to a fourth of an inch, a few of the 
circular fibers are divided. This permits the longitudinal fibers to 
contract, and thus shortens the vaginal portion of the cervix. 

By far the most frequent and important lesion that occurs in the 
connection of the uterus and vagina is the imperfect invagination of 
the anterior wall of the cervix, which has been described under the 
head of pathology. To overcome this deformity, I have adopted 
the following plan of treatment : The patient is placed on her left 
side, and Sims's speculum is introduced. The posterior lip of the 
cervix uteri is seized with a tenaculum, and the cervix drawn back- 
ward toward the hollow of the sacrum. This puts the anterior 
column of the vagina on the stretch, at the point where it is reflected 
on the cervix. The vaginal wall is then divided transversely with 
the scissors, about three fourths of an inch from the os uteri, the 
incision being from a quarter to three eighths of an inch deep 
(Fig. 37). The vaginal wall is dissected up, so that wdien the incised 
portion is put upon the stretch the sides will come together. In 
other words, the upper and lower edges of the incised central por- 
tion of the vaginal wall are dra^vn apart, and the sides brought 
together to flll the space, so that the transverse incision now ap- 
6 



66 



DISEASES OF WOMEN. 



pears as a longitudinal one. Three or four sutures are introduced, 
to keep the parts together till they unite (Fig. 38). 




Fig, o7. — Operation for imperfect invagination. The incision. 

If the uterus is slightly below its normal level, and inclined to 
retroversion (a condition not uncommon in anteflexion), much benefit 
will be obtained by introducing a double-lever pessary, largest at its 
posterior extremity. This will hold up the uterus, and, by making 




Fig. 38. — Operation for imperfect invagination. Sutures in position. 

pressure in the posterior vaginal cul-de-sac, draw the cervix back- 
ward, and thus hold the edges of the wound together and favor 
union. The effect of this simple and safe operation is to bring 
the anterior wall of the cervix farther down into the vagina, and 
permit it to extend backward more toward the axis of the pel- 
vis, where it ought to be. This plan of treatment I have found to 
be sufficient for the rehef of flexion of the cervix uteri in many 
cases. 



FLEXION^S OF THE UTERUS. 



67 



The treatment of flexion of the body of the uterus requires first 
that the organ should be made straight, and then that it should 
be kept straight, as already stated. The first ob- 
ject can be accomplished most easily by the use | i 
of Elliott's uterine adjuster (Fig. 39). I am in- ; j 
debted to Dr. T. Gr. Thomas for the knowledge | j 
of the method of using this instrument. It ; i 
looks like a uterine bougie, with a round metallic 
disk at its end. By turning this disk, the point 
of the instrument can be bent forward or back- 
ward at the will of the operator. In using it to 
straighten the flexed uterus the instrument is 
carried forward and passed into the uterus ; the 
disk at the end is then turned in the reverse di- 
rection, and the instrument, carrying the body 
of the uterus with it, is bent in the opposite 
direction until the body and cervix uteri are 
brought into line with each other. There are 
certain precautions necessary in using this instru- 
ment to straighten a flexed uterus, but these will 
be brought out in the history of cases which fol- 
low. 

In straightening the uterus with Elliott's ad- 
juster it is useful to bend the uterine body back- 
ward beyond the line of the cervix when this can 
be done without causing much pain. The stretch- 
ing of the wall of the uterus at the point of flex- 
ion stimulates nutrition and gives strength to the 
weak part. By repeating this treatment many 
times, much relief is given, and much progress 
made toward finally overcoming the deformity. 

To keep the uterus straight in anteflexion of 
the body, two of the many methods commended 
I have found useful — the first being the use of 
a retroversion pessary to draw the urine back- 
ward, as suggested by Emmet, in order to bring 
line with the body of the uterus. 

The other means is the intra-urinary stem with ' a vaginal 
pessary to keep it in position — the glass or hard-rubber stem and 
vaginal pessary, with a cup devised by Thomas, beino^ mv choice 
(Fig. 44). 

In using the intra-uterine stem the greatest possible care should 



Fig. 39.— Elliott's uter- 
ine adjuster. 



the 



cervix on a 



es DISEASES OF WOMEN. 

be employed because of the great danger of exciting inflammation. 
Before resorting to the use of this instrument all congestion and 
irritability should be subdued as far as possible, and the uterus 
should be trained to tolerate a foreign body in its cavity. To 
accomplish this, all the ordinary means for the relief of metritis 
should be employed. Cocaine, which has proved to be of great 
value in other departments of surgery, is a great help to the .gynae- 
cologist, especially in the management of the class of cases now under 
consideration. By the use of this agent the extreme hyperaesthesia, 
which renders the use of the sound not only painful but dangerous, 
can be completely overcome. When I first began to use cocaine 
I was fearful that, while the sound or adjuster could be used without 
pain under the effects of this local anaesthetic, there might be as 
much danger of causing inflammation as there would be without it ; 
but experience has proved that my fears were groundless. I prefer 
a two-per-oent solution, and depend upon repeated applications to 
produce the desired effect. This is a safe way of using cocaine. At 
the time of using ths solution it should be at about the temperature 
of the body, and it should be introduced with a pipette. I apply 
it to the canal of the cervix and os internum, and in a few minutes 
pass the sound just beyond the internal os. If this causes much pain, 
I make another application and try the sound again ; and if it can be 
easily introduced, I permit it to remain in the canal for a minute or 
two. 

At the next treatment I repeat the application and use a larger 
sound, and, if this is well tolerated, I pass the pipette into the cavity 
of the body and apply the cocaine. If that causes no pain, I use the 
Elliott adjuster and straighten the uterus, if I can do so without 
causing suifering. At each subsequent use of the adjuster I apply 
cocaine until the tenderness disappears. Then the cocaine is omit- 
ted, and if the sensitiveness does not return I feel sure that the stem 
pessary will be tolerated. 

I am inclined to think that cocaine aids in relieving inflamma- 
tion. Its immediate effect is to relieve congestion, and although 
the hypersemia returns after the effect passes off, I do not believe 
that it does so to the original extent. 

Defects of the canal of the uterus are frequently associated with 
flexion. In some cases the whole canal of the cervix is too nar- 
row, and in others there is a stricture at the internal os. To over- 
come these defects, and to aid in correcting the flexion, several 
methods have been employed, the chief among them being incision 
and dilatation. When the constriction is at the internal or external 



FLEXIONS OF THE UTERUS. 



69 




Fig. 44. — Stem pessary of Thomas. 



OS, or both, I prefer incision followed by the use of the intra-uterine 
stem, or the frequent passing of the uterine sounds of different sizes. 
Where the whole canal is contracted, 
I prefer dilatation. This may be easy 
and gradual, or forcible. The first 
consists in passing graduated sounds, 
the other in using the uterine dilator 
(see Fig. 16). 

I prefer the forcible dilatation 
when there are no contra-indications, 
such as extreme sensitiveness ; but I 
do not approve of carrying the dila- 
tation beyond that which is sufficient 
to admit a No. 10 or 12 English 
sound. The extreme dilatation prac- 
ticed by some, which is carried to a 
point sufficient to admit the index- 
finger, is dangerous and unnecessary. Incision and dilatation are 
necessary when the canal is undersized, and should be employed only 
when that condition exists. Little permanent good will come of this 
treatment except as preparatory to the use of the stem. In cases of 
flexion of the body and cervix it follows, as a matter of course, that 
all the means given above for the treatment of each must be em- 
ployed. 

Finally, it may be noted that success in the treatment of flexions 
depends upon the careful use of the means suggested, avoiding, as 
far as possible, the ever-present danger of exciting inflammation, 
which may make matters far worse. And much depends upon the 
age of the patient. It is always more easy to correct deformities 
in the young than in those of more advanced life. It should also be 
borne in mind that there is a tendency for the flexion and all con- 
sequent symptoms to return unless utero-gestation follows. On this 
account I have classified the results of my treatment in married 
women under two heads, viz., relieved, and cured. The former em- 
braces those who have been relieved from dysmenorrhcea, but have 
remained sterile, and the latter those who have been relieved and have 
borne children. 

ILLUSTRATIVE CASES. 

Anteflexion of the Cervix Uteri, Sims's Operation. (Relieved.") — 
This patient was a strong, healtliy lady, wlio began to menstruate at 
the age of fourteen years. She continued in good health, and the 
menses were normal, except that she had more discomfort than be- 



70 DISEASES OF WOilEX. 

longs to perfect health. About the age of eighteen, menstruation 
became more painful, and she had some backache and occasional 
leucorrhoea. These symptoms increased but little until she was 
mamed, at twentv-two years of age. Then she began to have 
dysmenorrhoea, and occasional menorrhagia. The leucorrhoea and 
backache became more persistent and her strength failed. The 
pain at the menstrual period was not very severe ; in fact, it was 
not at all like the violent pain often present in flexion of the body 
of the utenis, but it made her life quite miserable at that time. 
About eighteen months after her mai'riage she first applied for 
treatment, when the above symptoms were related. 

The OS externum pointed toward the vulva, and the vaginal por- 
tion of the cervix was slightly flattened from below upward. The 
invagination of the cervix anteriorly was nearly normal, but not in 
2)ropoition to that of the posterior wall, which appeared to be ex- 
cessive. The body of the uterus was in its normal position ; the 
sound could not be passed until the cervix was dragged backward 
and brought in a line with the body. 

She was treated for a time to relieve her congestion and cervical 
endometritis, and then the posterior wall of the cervix was divided 
according to Sims's method. When the edges of the wound healed, 
there was considerable inversion of the mucous membrane, showing 
that it was redundant. The protruding portions were trimmed off, 
and then the results of the operation were quite satisfactory in ap- 
pearance. She was relieved of all her symptoms, for a time at 
least, but remained sterile, although the canal was large enough, and 
the sound could be passed. Three years afterward she was seen, 
and then she was complaining of leucorrhoea and occasional pelvic 
pains. 

This case was treated eight years ago, and is the last one in 
which I have performed Sims's operation for flexion. 

Extreme Anteflexion of the Cervix Uteri; Dysmenorrhoea. (Re- 
covery.) — The patient was first seen at the age of twenty-five. Her 
past history was that of good health. MenstiTiation occuiTed first at 
fifteen, and from that time onward was normal, except that it was 
accompanied with pain. During the first few years after puberty 
the pain was slight, but it gradually increased until it was suffi- 
ciently severe to unfit her for everything during the menstrual 
period. Her general health began to fail ; she lost flesh, and became 
very neiwous and irritable, and it was on this account that she sought 
relief. 

I found that the anterior wall of the cervix uteri was on a line 




FLEXIONS OF THE UTERUS. 71 

with the anterior wall of the vagina, and the os pointed toward 
the pubes. The posterior wall of the cervix projected into the va- 
gina far more than normal ; in fact, the cervix was 
hooked upward. The body and fundus were in the 
normal position. 

Fig. 45 will give an idea of this form of flex- 
ion. It gave the impression that in tlie descent of 
the uterus the anterior wall of the cervix had been 
arrested in its progress by the vaginal wall, while 
the posterior wall of the uterus descended beyond ''^ ^^nJeflcxkm^"^^ 
the normal extent. It was very difficult to pass the 
sound ; to do so, the uterus had to be raised up in the pelvis and 
partially retroverted. Drawing the cervix forcibly backward toward 
the sacrum developed a band of the anterior wall, which ran from 
the extreme end of the cervix upward and forward about an inch 
and a half, and there blended with the vaginal wall. It was easily 
seen that this abnormal attachment of the vagina was the cause of 
the flexion of the cervix. 

Preparatory treatment was employed for a short time, to reduce 
congestion, and then the operation, already described, to correct the 
invagination of the cervix, was performed. The ridge of anterior 
vaginal wall was divided a little less than an inch from the cervix, 
and then very gentle traction was sufficient to draw the cervix back 
into its proper relations witli the body of the uterus. The wound, 
which was made at right angles to the axis of the vagina, became 
parallel to it, when the cervix was carried back into its normal po- 
sition. It was closed with silk sutures, carried deep down into the 
wall of the vagina, to make sure that the deeper portions of the 
wound were coaptated. When the sutures were tied, the invagina- 
tion was seen to be complete, and the cervix was carried well back, 
quite as far as it should be ; there was also a noticeable traction 
on the sutures, because the cervix inclined to flex forward again. 
To correct this, a stem-pessary was introduced, which extended about 
half-way up the cavity of the body of the uterus. This was held in 
position at flrst with a marine lint tampon, and when the wound 
healed the stem was held in place by the retaining pessary. The 
operation was done without ether, and the patient did not com- 
plain of pain, except when the stem was introduced into the uterus. 

Ten days after the operation the sutures were removed and the 
union was complete ; the stem was still left in place. After another 
week had gone, there was considerable congestion in the canal, indi- 
cated by a free discharge. The stem was removed, and an applica- 



72 DISEASES OF TTOMEN". 

tion of tannin and glycerin made. After the sutures were removed, 
the douche of borax and warm water was used daily, and once a 
week the stem was removed and the canal painted with tannin and 
glycerin. The next menstrual period was without the severe pain 
which she suffered before the treatment. Still there were backache 
and pelvic tenesmus. The stem was left in place during menstrua- 
tion and for three weeks after, but during that time it was removed 
every week, and the apphcation of tannin made. 

The second menstriTation after the oj^eration, the first after the 
removal of the stem, was painless. Subsequently there was no re- 
currence of the flexion, and her menstruation has continued regu- 
lar and without pain. It is now three jears since she was treated, 
and she remains well and free from dvsmenorrhoea. 

I may add here, that in all cases of anteflexion of the cer^flx, due 
to imperfect vagination, the treatment given aboye has been suc- 
cessful. 

Anteflexion of the Body and Cervix Uteri with Prolapsus. (Eecov- 
ery.) — This patient was a little below the medium size, but was 
strong and active. She began to menstruate at thirteen, and con- 
tinued to do so rather irregularly. She generally went over time a 
varying number of days. From the first, menstruation was painful, 
the pain gradually increasing from month to month and year to year. 
This pain was characteristic of fiexion ; it began before the flow 
was relieved, diminished when the flow was well estabhshed, and 
subsided entirely on the second day. The pain was referred to the 
uterus, and was intermittent. From puberty to about twenty-one 
years of age her health was perfect between the menstrual periods. 
She then began to suffer from backache, leucorrhoea, occasional ova- 
rian pain, and gradually her digestion became impaired, and the 
nervous system fretted. 

She was first seen at the age of twenty-four, when the above 
history was obtained. It was evident that all her symptoms were 
increasing in seyerity ; general congestion and tenderness of the 
vagina, uterus, and ovaries, were found at the examination. The 
OS externum pointed toward the vulva, and the fundus could be felt 
through the anterior wall of the vagina. The cervix was normal in 
size, and projected into the vagina in due proportions, anteriorly and 
posteriorly. The uterus rested low down in the pelvis, and the cer- 
vix appeared to be bent forward by the pressure upon the pelvic floor. 
These signs, obtained by touch, were all confirmed by the sound 
and speculum. The sound was passed through the os internum with 
difficulty at first. There was no change in the stiTictures of the 



FLEXIONS OF THE UTERUS. 73 

Uterus except the flexion ; the congestion was well marked, and there 
was slight lencorrhoea, indicating that cervical endometritis was 
being developed. 

The treatment of this patient consisted in remedies to improve 
digestion. Bromide of sodinm was given to quiet her nervous sys- 
tem. Locally, the hot- water douche was employed ; the os exter- 
num was dilated, and tincture of iodine applied to the cervical 
canal ; the uterus was raised to its proper elevation, and held there 
at first with a tampon, and afterward with a small Peaslee's pessary. 
The following week the internal os was dilated, until it admitted 
a ^o. 10 sound, and the iodine was also repeated. This caused much 
pain, and compelled the patient to rest in bed a few days, during 
which time the hot douche was continued. After this, the uterus 
was made straight by using Elliott's adjuster once a week. The 
douche and iodine were continued, and this completed the plan of 
treatment. 

For six months this course of local treatment was followed out, 
the constitutional treatment being varied as the symptoms changed. 
The tenderness and congestion first disappeared, and the pain dur- 
ing menstruation gradually became less and less, and finally ceased 
entirely. 

The patient remained under observation two months longer, and 
then married, and seven months later her physician reported to me 
that she was four months pregnant. 

Anteflexion of the Body of the Uterus ; Stenosis at the Os Inter- 
num, treated with Stem-Pessary. (Recovery.) — This patient had good 
health, but was of a highly nervous temperament, a condition which 
had been increased by a severe and prolonged education. She be- 
gan to menstruate at fifteen, and had dysmenorrhoea from the 
beginning. She managed to get along by resting at the menstrual 
periods, and bearing her suffering as best she could, but at the age 
of twenty-eight gave up, and sought advice. Her general health 
at that time was impaired, and she was quite despondent. When 
first examined, the usual signs of anteflexion of the body of the 
uterus were found. The cervix was also slightly bent forward. 
The canal of the uterus was of full size, except at the internal os ; 
a small probe only could be passed at that point. The uterus was 
quite tender, and there was some catarrh of the cervical mucous 
membrane. Tonic and sedative treatment was begun, and the strict- 
ure was incised on two sides, with the hysterotome. 

After this, a sound was passed twice a week for a time. The pa- 
tient was much relieved by this treatment, but still suffered pain at 



74: DISEASES OF WOMEN. 

the menstraal periods. The pain returned to a certain extent, at 
each menstruation, and at the end of a year treatment had to be re- 




FiG. 46. — Skene's hysterotome. 

newed. At that time the patient appeared to be as badly off as 
when first seen. Dilatation of the canal and straightening the uterus 
with Elliott's adjuster gave some relief. More thorough treatment 
was advised, but she would not consent to give her whole time to it. 

Four years later the patient returned in mnch worse condition 
than when first treated. The tissues of the uterns were much hard- 
er, and there was more tenderness. Great pain was experienced upon 
passing the sound, and any effort to straighten the uterus was un- 
bearable. Sleeplessness was now a prominent symptom, and she 
was obliged to take morphine at the menstrual periods. 

I prescribed tbe rest-treatment, with tonics, bromides, massage, 
and the hot-w^ater douche, and the application of tincture of iodine 
to the cervix uteri and the upper part of the vagina. When the 
general health had been improved by two months of this treatment, 
the cervical canal was dilated, under the use of cocaine, until it ad- 
mitted a JSTo. 12 sound. The uterus was then straightened with the 
Elliott adjuster, and a glass stem-pessary introduced. Althougli she 
was kept quiet after the introduction of the stem, the suffering was 
so great that at the end of two hours it had to be removed. The 
general treatment was resumed for about four days, and the stem 
was again used ; this time it was worn for five days, but had to be 
again removed, owing to the pain it caused. The irritation was 
again subdued by the hot douche and cocaine applied to the canal of 
the cervix, and occasionally an application of iodine and carbolic acid 
was made. A week later the stem was used again ; it then caused 
less pain, but she had to remain in bed, and there was still consid- 
erable distress. There was also a marked leucorrhoeal discharge. It 
was necessary to remove the instrument about every five days, and 
treat the cervical endometritis. 

Three weeks passed before the patient could be trusted to walk 
around, and it w^as two months longer before she could walk out and 



FLEXIONS OF THE UTERUS. 75 

ride without causing pain. The dysmenorrhoea was less severe each 
month, and finally subsided entirely. The stem was worn altogether 
about four months ; during all that time the case had to be watched 
and treated for a recurring endometritis, but finally the recovery was 
complete. 

Two years have passed since the treatment was completed, and 
the patient remains well. The chances are, however, that the flexion 
will recur. 

It will be noticed that the stem caused much irritation, and re- 
quired constant watching. This I find is the case very often. There 
are few patients who will tolerate the stem unless great care is tak- 
en, and they are treated the moment that symptoms appear. The 
longer the trouble has existed, the more difficult it is to use the 
stem. The uterus becomes more dense in structure and more sensi- 
tive in old cases, and the results of treatment are not very satisfac- 
tory. This is the rule, and there are not many exceptions to it. 
The patient whose case I have jnst described is one of the oldest 
that I have ever successfully treated for flexion. 

All the cases here given are intended to show the different forms 
of flexion, and the various methods of treatment employed. It will 
be seen that my object is not to use one method of treatment in all 
forms, but to adapt the treatment to the peculiar requirements of 
each case. 

Finally, I may add that I have succeeded in relieving all cases 
of flexion, of whatever form or degree, temporarily at least, by the 
treatment described, excepting when there were complications, such 
as ovarian disease, or the results of old inflammations. A consider- 
able number have entirely recovered, and borne children. 



CHAPTER y. 

DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 

ANATOMY. 

The Pudendum. — The pudendum comprises all those parts that 
are situated at the outer and lower portion of the pelvis. It is 
bounded above by the lower part of the abdomen, on either side 
by the thighs, and below by the perineeum. In general outline it is 
wedge-shaped, the edge being downward. 

The several parts are the mons veneris, the labia majora and 
minora, the clitoris, and the hymen. 

The mons veneris is a mass of tissue which covers the sym- 
physis pubis, and occupies the triangular space formed by the junc- 
tion of the abdomen and thighs ; it is composed of fatty tissue and 
rather thick integument, which, after puberty, is covered with hair. 
At its lower border it is divided into two folds by the upper por- 
tion of the urogenital fissure. The labia majora are two prominent 
rounded folds of integument, continuous above with the mons vene- 
ris, which extend downward to the perinseum. They are formed 
by integument covered with hair on the outer side ; the inner sur- 
face is more like mucous membrane in general appearance, but it 
contains sebaceous glands instead of mucous follicles. The tissues 
of the labia beneath the skin are, connective tissue, elastic elements, 
and fatty lobules with underlying adipose structure. The vascular 
supply is abundant, forming a venous plexus. 

The labia minora, also called the nymphge, are two small folds of 
mucous membrane, situated upon the inner sides of the labia majora, 
and extending downward until they meet posteriorly, and form the 
thin circular band, the fourchette or frgenulum vulvse, which extends 
across at the posterior part of the opening of the vagina outside of 
the hymen. The outer surfaces of the labia minora are continuous 
with the labia majora, and the inner surfaces with the mucous mem- 
brane of the vestibule. 



DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 77 

The clitoris is analogous to the penis, but possesses neither corpus 
spongiosum nor urethra ; it is erectile in structure, and is described 
as having three parts— the crura, corpus, and glans. The crura are 




Fig. 47. — The external genitals of a woman who has borne children. 

oblong, spindle-shaped processes, formed by the bifurcation of the 
corpus ; they are attached to the rami of the ischium and pubes. The 
corpus is located in the median line beneath the pubic arch, and 
terminates anteriorly in a rounded extremity, the glans. 

The relations of the clitoris and the labia minora are as follows : 
Each labium divides anteriorly into two folds, which surround 
the glans clitoridis, the superior folds meeting to form the preputium 
clitoridis ; the inferior folds being attached to the glans, and forming 
the frsenum. 

The vestibule is the triangular, smooth surface, bounded above 
by the clitoris, on either side by the nymphae., and below by the an- 



78 DISEASES OF W0ME:S". 

terior vagirial wall. Just above the junction of the vestibule and 
vagina the meatus urinarius is situated. It is distinguished bj its 
projection beyond the general surface of the vestibule. The hymen 
is a thin semi-lunar fold covered on both external and internal sur- 
faces with mucous membrane, and stretches across the posterior part 
of the orihce of the vagina. It is a continuation of the vagina 
(Budin). In fact, the hymen covers the orifice of the vagina, closing 
it completely, except a small, crescentic opening just below the mea- 
tus urinarius. It varies in different subjects in regard to its shape, 
hence the above description can only be taken as that of the typical 
form — the deviations from this type will be referred to in connec- 
tion with the pathological conditions of the hymen. 

The meatus urinarius is situated in the median hne, at the junc- 
tion of the lower margin of the vestibule and the margin of the an- 
terior wall, about three quarters of an inch below the clitoris. It is 
kept closed by the muscular tissue of the urethra, and presents a 
puckered appearance and projects slightly beyond the general plane 
of the vestibule. 

The line of junction between skin and mucous membrane runs 
along the base of the inner aspect of the labium majus, passes down 
beside the base of the outer aspect of the hymen, and through the 
fossa navicularis. 

The deeper structures of the external parts of generation are 
mostly glands and blood-vessels with connective tissue — the arrange- 
ment of the two latter giving the characteristics of erectile tissue. 

The glands are of two kinds, the sebaceous and mucous. The 
sebaceous glands are abundant in the tissues of the nymphge ; they 
furnish a yellowish-white secretion, which has a peculiar odor. In 
those who are not quite cleanly in their habits this secretion accumu- 
lates beneath the upper folds of the nymphae, around the glans cli- 
toridis. 

The mucous glands are of two varieties — the glandulse vestibu- 
lares majores and the gland ulse vestibulares minores. 

The glandulae vestibulares minores are about six in number, and 
are situated about the meatus urinarius ; they are of the compound 
racemose variety, and have short ducts with large orifices. Some- 
times one or more of these ducts is found, much enlarged, and look- 
ing like a cul-de-sac^ large enough to admit the point of a small 
catheter. 

The glandules vestibulares majores are two in number and about 
the size of a pea, and are of a reddish-yellow color. They are situ- 
ated at the posterior extremity of the bulbi vestibuli, and are par- 



DISEASES OF THE EXTERNAL ORGANS OF GENERATION. Y9 



tiallj included in the bulbi, or, more properly speaking, the glands 
and the bulbi overlap each other. 

They, like the glandulse minores, are of the compound racemose 
variety, and their acini open into a duct, more than half an inch in 
length, which is wide where it leaves the gland, but becomes nar- 




FiG. 4F. — The superficial veins of the perinEeum (Savage): li^g^ crura clitoridis ; o, cor- 
pus clitoridis; 1, 2, 3, corpus cavernosum urethras; 5, superior perineal and obtura- 
tor veins ; 6, veins of communication with superior epigastric veins; 8, 9, 10, pudie 
vein and primary branches ; c?, tuberosity of ischium ; o, coccyx ; G, vulvo-vaginal 
gland ; a, anterior border of gluteus maximus muscle ; B, superficial sphincter and 
muscle ; ^, erector clitoridis muscle ; A, left crus clitoridis, 

rower toward its orifice. These ducts, in their course, run along the 
inner side of the vaginal bulbs, and terminate in front of the hymen, 
about midway from the base of the vestibule and the posterior border 
of the hymen, or its remains. 



80 



DISEASES OF WOMEN. 



The remainirig deeper structures of the pudendum of special in- 
terest are cellular tissue and two masses of blood-vessels, known as 
the bulbi vestibuli vaginae. These bulbs of the vaginal vestibule 
are, when distended with blood, about an inch long ; they are located 
on each side between the vestibule and the pubic arch. Thej are 
composed of reticulated veins and erectile tissue. The upper ends 
of these bulbs are pointed, and communicate, by an intervening 
small plexus, the pars intennedia, with the vessels of the glans cli- 
toridis (Fig. 48). 

The oriiicium vaginae differs greatly in size and general appear- 




- ^4; sR "LD 




h,SCHiiK^^coyK.-> 




Fig. 49. — ^External genitals of virgin. 



ance in the virgin, in those accustomed to sexual intercourse, and in 
those who have borne children (see Figs. 49 and 47). 



DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 81 

In virgins the hymen is present, as a rule, and its upper crescen- 
tic border, with its concavity looking toward the urethral opening, 
forms the vaginal orifice. There is a considerable variation in the 
shape of the hymen, and, though there are deviations from the nor- 
mal type, they are not of necessity morbid states, but rather pecul- 
iarities of formation. The most common of these are the hymen 
cribriformis (Fig. 50), which has a number of small openings ; the 




Fig. 50. — Cribriform hymen. Fig. 51. — Annular hymen {\). Fig. 52. — Fimbriate hymen. 



hymen annularis (Fig. 51), which has one small central opening ; 
the hymen fimbriatus (Fig. 52), so called because it is fringed some- 
what like the extremity of a Fallopian tube. 

The hymen is usually lacerated in several places during the first 
coitus, but of some instances this does not take place. Cases have 
been seen in married women in whom the hymen is very elastic and 
distensible. Hyrtl mentions one specimen, in the museum at Halle, 
where the hymen is perfect, though the woman 
had given birth to a seven months' child. The 
carunculse myrtiformes are a number of isolated 
elevations of mucous tissue about the orifice of 
the vagina, which most authors claim to be the 
remains of the lacerated hymen. Schroeder has x^ 

pointed out that these elevations or carunculse Fig. 53. — i?, Rectum, 
are produced by child-bearing, and not by simple 
laceration of the hymen. Clinical observations 
confirm the views of Schroeder. 

Development and Malformations of the Vulva. 
— During the second month of fetal life the rec- 
tum, allantois, and M tiller's ducts communicate, but there is as yet 
no opening of these to the exterior (Fig. 53). 
7 




allantois (bladder) and 
M duct of iliiller (va- 
gina) ; X, depression 
of skin -which grows 
inward and forms the 
vulva (Schroeder). 



82 



DISEASES OF AVOMEK 





has extended inward 
and become continuous 
with the rectum and 
allantois forming the 
cloaca {CT). 



Later on, about the tenth week, the genital cleft forms ; this is a 
depression in the skin which gradually extends deeper and deeper 

nntil it communicates with 
the allantois and the rectum, 
and becomes the cloaca 
(Fig 54). 

The structure which lies 

54.— The depression Fig. 55.— The cloaca is between the rectum and the 
dividing- into urogen- allpntniQ o-rnwQ in a rlnwn 

itai sinus {Su) and aiiantois grows m a aown- 
anus by downward ward direction, dividing the 
seprum.''^ P'"°'"^ cloaca into two parts; that 
which is situated anteriorly 
is the urogenital sinus into which Mliller's ducts open ; the posterior 
part becomes the anus, while the lower end of this downward growth 
forms the perinseum (Fig. 55). 

The upper portion of the urogenital sinus, becoming more and 
more contracted, forms the urethra, the lower part remaining as the 
vestibule (Figs. 56 
and 57). 

As has elsewhere 
been stated, the 
ducts of Miiller unite 
to form the vagi- 
na. The clitoris is 
formed from the 
genital eminence, 
and the labia minora from the edges of the genital cleft. 

From this brief consideration of the manner of formation and 
development of the external genital organs, their maKormations are 
the more readily understood. Thus, if the depression which is 
known as the genital cleft fails to be formed, complete atresia of the 
vulva results. If the partition between the rectum and vagina is not 
developed, the condition known as atresia of the anus results. Fi'om 
the description already given, it will be seen that this is nothing more 
than the continuance of the cloaca. In other cases the urethra fails 
to be developed, and there is then a persistence of the urogenital 
sinus, or what is commonly known as hypospadias. 

Hermaphroditism. — In hermaphroditism both ovaries and testi 
cles, or one of each, exist in the same individual ; these cases are 
extremely rare, though they have been observed and described by 
Hildebrandt, Bannon, and others. In false or pseud o-hermaphro- 
ditism a condition exists in which the external genitals appear to 





Fig. 56. — The perineal body Fig. 57. — The upper part of 



IS completely 
(Schroeder). 



formed 



the urogenital sinus has 
contracted into the urethra; 
the lower portion persists 
as the vestibule (*Sw), 
(Schroeder). 



DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 83 



belong to the opposite sex. Thus, the clitoris may be so hypertro- 
phied as to resemble a penis, and the labia minora be so closely in 
apposition as to be mistaken for a scrotum ; or, on the other hand, 
the individual may be in reality a male, in whom the condition of 
hypospadias may exist, and thus the appearances seem to indicate a 
female. A case is reported by Otto, in which the external genitals 
of the individual so resembled those of a female that he lived as the 
wife of three husbands without 
the fact that he was a male being 
discovered ; and then the mys- 
tery was only solved by medical 
examination. Fig. 58 represents 
the appearance of the organs in 
this remarkable case. In these 
cases of false hermaphroditism 
careful examination will settle 
any doubts which may have aris- 
en. The parts simulating both 
scrotum and labia, when exam- 
ined, will, if the individual is a 
male, contain the testicles ; and, 
if a female, no such body will be 
found. 

It is, of course, to be borne 
in mind, that owing to the non- 
descent of the testicle, no body 
might be found, and still the 
individual be a male, and, on the 
other hand, that a prolapsed 
ovary might be mistaken for a 
testicle. A digital examination 
should also be made through the 
rectum for the uterus and ovaries. If the age of puberty has ar- 
rived, the presence or absence of menstruation will be a valuable 
diagnostic sign, and great aid may be derived from a study of the 
other portions of the body, as the breasts and the face, in order to 
detect the beginning beard, or the voice, to distinguish its tones. It 
is, of course, very important to make a correct diagnosis ; but when 
this is done, the physician's duty is at an end, so far as being of 
any service to the patient. 




Fig. 58. — Spurious hermaphroditism (Simp- 
son), case of hypospadias in the male 
making the external organs simulate 
those of the female : a, a, lobes of scro- 
tum ; B, imperforate penis, 1^ inch long ; 
E, perineal fissure, l\ inch deep, lined 
with mucous membrane, at bottom of 
which the urethral orifice, n, is seen ; c, 
the split urethra with openings, f, of 
glands beside it. 



84 DISEASES OF WOMEN". 

DISEASES OF THE PUDENDUM. 

Vulvitis. — Primary inflammation of the vulva is quite rare, if 
the specific form and the vulvitis of children are excluded. In 
nearly all the cases that have come under my observation the inflam- 
mation of the vulva has been secondary to and caused by some pre- 
existing affection. When it is due to gonorrhoea, syphilis, cancer of 
the uterus, or vaginitis, it must necessarily be treated as a complica- 
tion of these diseases, rather than as an affection in and of itself. 

Uncomplicated vulvitis may occur in several forms — as a sim- 
ple erythema, a purulent inflammation, or as a follicular inflam- 
mation. 

The erythematous variety is characterized by a general redness of 
the vulva, limited to the mucous surfaces, though sometimes it ex- 
tends to the skin. It is usually transient, passing away without much 
treatment. 

The purulent form is more deflned. The parts are red, and cov- 
ered with a copious formation of pus. The epithelium rapidly ex- 
foliates, leaving a raw-looking surface. Occasionally only small 
patches of ulceration are to be seen, but these are neither large nor 
are they deep, as a rule. 

In follicular vulvitis the mucous membrane generally is not much 
changed in appearance; sometimes it has a deeper color, but the 
whole surface is studded with small, red points, which on close in- 
vestigation are found to be the orifices of mucous follicles. The 
size and number of these inflamed spots vary iu different cases. 

In this and in the purulent form the discharge is increased by a 
free secretion from the mucous and sebaceous glands, and this gives 
rise to a very disagreeable odor. There is also in most cases consid- 
erable pruritus. 

Causation. — In regard to the causes of vulvitis, it is evident that 
the strumous diathesis and the lymphatic temperament predispose to 
it. All the cases that I have seen, which could not be traced to 
some pre-existing or specific cause, have been in strumous or phleg- 
matic women. 

Age also has its influence. The purulent variety occurs in chil- 
dren, while the follicular form occurs most frequently in the aged. 

8ymjptomatology . — These are not diagnostic. The discharge, 
heat, tenderness, and pruritus are the chief symptoms, but they 
all occur when the vulvitis is associated with vaginitis, and similar 
symptoms occur in many of the eruptive diseases of the vulva. 

Physical 8igns. — These are the same as those presented by in- 



DISEASES OF THE EXTERN"AL ORGAN'S OF GENERATIONS^. 85 

flammation of mucous membranes generally, and hence need not be 
given here. 

Diagnosis. — This is made bj inspection, and a careful .exclusion 
of all other affections, such as eruptive, specific, or malignant 
disease. 

Treatment. — The chief objects, in the management of vulvitis, 
are to keep the parts clean, and to separate the inflamed surfaces. 
This is difficult to do in children, and hence the complete relief 
of this affection in the young is not by any means easily effected. 

In vulvitis of women I have of late years relied upon frequent 
washing with a solution of borax or boracie acid, two or three 
times in the twenty-four hours, and then after drying the parts, ap- 
plying thoroughly a dry powder of subnitrate of bismuth, oxide of 
zinc, or iodoform. This method answers very well if the patient 
has a nurse who can carefully employ the treatment. Equally good 
results have been obtained by applying to the parts, after bath- 
ing thoroughly, a solution of sulphate of zinc, three or four grains, 
three ounces of water, and one ounce of fluid extract of hydrastis 
Canadensis, or nitrate of silver, two grains to the ounce of water. 
After applying either of these lotions, a small pledget of absorb- 
ent cotton should be placed between the labia, to keep the surfaces 
apart, and to absorb the purulent discharge. 

Inflammation of the Vulvo-vaginal Glands. — Inflammation of 
these glands in the great majority of cases is due to vulvitis. The 
inflammation extends into the ducts and finally to the glands them- 
selves. While this is sometimes the result in simple vulvitis, it is 
far more likely to occur when the inflammation is gonorrhoeal. In 
some cases the inflammation does not extend beyond the duct, the 
gland itself escaping, and then there is but little discomfort experi- 
enced by the patient unless the purulent discharge keeps up a cir- 
cumscribed inflammation of the vulva around the opening of the 
ducts. When the glands are involved, the symptoms are those of 
an inflammation of the deeper structures. The closing of the ducts 
of these glands may result in the formation of cysts, by the retention 
of the secretion. 

Symptomatology. — The patient will usually detect the inflamma- 
tory condition before the physician is consulted. This portion of 
the pudendum will be hot, sensitive, and painful ; pruritus may also 
be present. 

Physical Signs. — By inspection of the parts, redness around the 
mouths of the ducts will be found. The openings of these ducts 
are to be sought for, about the middle of the ostium vaginie, one od 



86 DISEASES OF WOMEN". 

each side, just in front of the hymen, or the carunciilse myrtiformeSo 
By palpation a hard, circumscribed tumor will be found at the loca- 
tion of the gland. 

Prognosis. — The inflammation may gradually subside, or result 
in the formation of an abscess. If an abscess forms it will pursue 
the same course, and be recognized in the same manner as an ab- 
scess elsewhere. The pus may discharge tlirough the duct, or it 
may require surgical interference. Rarely the pus remains encysted 
for a long period. The inflammation may confine itself to the 
duct and not extend to the gland. In this case it will cause but 
little trouble, pain and pruritus being present for a short time, 
and disappearing with the subsidence of the inflammation, or the 
inflammation may result in adhesion of the wall of the duct, and, by 
occluding its lumen, prevent the escape of the secretion of the gland, 
and cause a cyst by its retention. Not infrequently the walls of 
such a cyst become inflamed, and an abscess results. 

Treatment. — The inflammation of these glands is to be treated 
in the same manner as is recommended for the treatment of in- 
flammation of the labia majora. 

When a cyst forms, and its contents can not be evacuated through 
the duct by pressure, it may be dissected out. Although the great- 
est care may be exercised, this can not always be done ; in that case, 
the cyst-wall, after being exposed by dividing the mucous mem- 
brane, may be opened freely, the contents of the sac removed, the 
wall of the sac thoroughly cauterized with carbolic acid, and the 
cavity permitted to heal from the bottom by granulation, its v\^alls 
being kept separated by packing with cotton in order to prevent its 
closing, and again filling. 

Inflammation and Abscess of the Labia Majora. — This inflamma- 
tion occurs in the connective tissue, which constitutes the greater 
part of the labia. It is often associated with vulvitis, or may be 
due to the secretions of the vagina, which are of an irritant char- 
acter. Blows or other injuries may also excite an inflammation in 
these tissues. This inflammation is characterized by redness and 
swelling; the latter is not circumscribed, as in the inflammation of 
the vulvo-vaginal glands, but is more diffuse. Like that, however, 
it is painful, and accompanied with pruritus. AVhen a swelling is 
formed in one of the labia, it may be due to simple inflammation, 
or it may be a hernia, an ovary, or a hematocele. 

Treatment. — The means employed for the treatment of inflam- 
mation of connective tissue elsewhere are indicated here. These 
are rest, evaporating lotions containing opium for the relief of the 



DISEASES OF THE EXTERN"AL ORGANS OF GENERATION. 87 

pain, salines, and flaxseed-poiiltices if the inflammation does not 
subside. If an abscess forms, it should be opened as soon as the 
presence of pus is determined ; the opening of the abscess, and the 
subsequent treatment of the wound, should be managed on strictly 
antiseptic principles. 

Varicose Veins of the Vulva. — The veins about the vulva, like 
those in other portions of the body, may take on a varicose condi- 
tion. This commonly occurs in those who have borne children ; and, 
indeed, pregnancy appears to stand in a causative relation thereto, 
although cases undoubtedly do occur in those who have never been 
pregnant. 

Causation. — Anything which obstructs the venous circulation 
will, by increasing the intravenous pressure, tend to produce this 
varicose condition, whether it be a pregnant uterus, a tumor, or, as 
mentioned by Winckel, the straining at stool, in case of obstinate 
constipation. 

Symptoinatology. — A patient may have well-marked varicose 
veins of the vulva, and yet be entirely unaware of the fact. Or a 
sense of heat and irritation, may be experienced of so disagreeable 
a nature as to cause her to consult a physician, when the presence 
of varicose veins may be recognized. In still other cases the full- 
ness due to the swelling is so great as to attract her attention, though 
other symptoms may be absent. 

Physical Signs. — Upon examination, in slight cases, the varicose 
condition of the veins is observed. There may, however, in more 
aggravated cases be so much tumefaction of the labia and other parts 
as to mask this peculiar condition of the veins. Holden describes a 
case in which a tumor existed as large as the head of a cliild. 

The diagnosis in these cases is to be made by excluding the other 
affections, by the methods which are elsewhere described. 

Treatment. — But little can be done in the way of radical treat- 
ment for this condition. The bowels should be attended to, so that 
there may not be constipation and the accompanying straining at 
stool. If the varicosity is marked, and shows a tendency to increase, 
some relief may be obtained by a pad, so applied as to give the 
veins the support which they lack by reason of the weakness of 
their walls. It should be constantly borne in mind that, wlien these 
veins assume a marked varicose condition, there is a possibility of 
their becoming so distended during pregnancy as to rupture at the 
time of delivery. 

Wounds of the Pudendum. — These injuries are of three kinds— in- 
cised, punctured, and contused. They are of great interest, owing 



88 DISEASES OF WOMEN. 

to the profuse hsemorrliage which usually occurs when the vessels 
of the bulbi vestibulares are wounded. Superficial wounds of the 
labia are not usually important ; it is only when the larger vessels 
of the bulbi are opened that profuse and dangerous hsemorrhage 
occurs. 

Incised and punctured wounds are usually caused by falling upon 
cutting instruments. I have not had any personal experience with 
such injuries. All I know about them I have gathered from Sir 
James Y. Simpson's obstetric work. He calls attention to several 
fatal cases of this injury, death occurring from hemorrhage. He 
also states that several of these fatal cases were supposed to be caused 
by criminal intent. I remember, when a boy, reading an account of 
a gypsy woman, in Scotland, who died from pudendal hsemorrhage, 
and her husband was tried for her murder. The defense set up 
was, that the wound was caused by striking against a stick while 
squatting down to urinate, in the woods, where they were encamped. 

Thomas records a case, not fatal, I believe, which was caused by 
a piece of china, from the breaking of a jpot de chambre. 

Symptomatology. — The symptoms are pain and profuse haemor- 
rhage, following an injury to these parts. The bleeding is suffi- 
ciently alarming to require an examination, when the character of 
the injury is at once detected. 

Causation. — The causes are traumatic, and need not be discussed. 

Treatment. — The treatment, commended by most authors, is to 
use cold applications and astringents, such as persulphate of iron and 
tannin, and if these are not sufficient, to enlarge the wound, pack 
it with antiseptic cotton, and apply pressure. To make the pressure 
effectual, the vagina should be tamponed, and a compress and band- 
age applied. 

I am satisfied that this kind of treatment must prove very un- 
satisfactory. Although I have had but little experience with acci- 
dental injuries of the pudendum, I have repeatedly encountered pro- 
fuse bleeding from vessels of the bulb, wounded while removing 
morbid gro^vths from the pudendum. In such cases I have found 
it most satisfactory to ligate the bleeding points, taking up the ves- 
sels en masse when several of them were wounded ; when it has 
been difficult to find the vessels and secure them in the deep wounds, 
1 have passed a strong sutui^e from the outer side of the labia into 
the vagina, and returned it so that it would include the bleeding 
vessels in its grasp when tightly tied. This controls the bleeding 
for the time, but occasionally it will start again, when the ligature 
becomes loosened, which it is likely to do in a few hours. When 



DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 89 

this occurs, the ligature should be tightened. If there is no subse- 
quent bleeding, the suture can be removed at the end of twenty-four 
hours, I ana sure that this is the most surgical as well as the most 
satisfactory way of managing haemorrhage in this region. Styptics 
and pressure, in some cases, will only conceal the bleeding, but not 
arrest it ; the blood will burrow in the soft tissues and complicate 
the injury, and also make ligature of the vessels more difficult. 

Contused Wounds of the Pudendum. — These are of two degrees of 
severity. A slight bruise, causing rupture of only a few small ves- 
sels (which very soon stop bleeding), gives rise to an ecchymosis, 
which quickly disappears. Occasionally inflammation follows and 
an abscess develops, which is managed in the usual way. 

Contused wounds, w^hich rupture the large vessels of the bulbi 
vestibulares, or varicose veins of the labia, if any such exist, produce 
pudendal hsematocele — i. e., an accumulation of blood in the loose 
cellular tissue of the parts. The pathology of this injury is the 
same as that of bruises or contused wounds generally. There are 
laceration of the vessels, and haemorrhage into the cellular tissue. 

In contusion of the pudendum there are two conditions which 
conspire to make the injury grave in character — the large size of 
the vessels wounded, and the loose character of the cellular tissue, 
which admits of a very large accumulation of blood. The size 
of the haematocele depends upon the size of the vessels lacerated. 
In case the vessel is small, the bleeding may be controlled by the 
pressure from the blood in the tissues; but when large varicose ves- 
sels or the vessels of the bulb of the vestibule are lacerated, the size 
of the hsematocele is very great. I have seen one nearly as large as 
the tw^o fists. 

The course and termination of haematocele vary. If the blood- 
clot is small, it may disappear by absorption, without causing much 
discomfort, after the first pain of the injury subsides ; but when the 
accumulation of blood is large, then inflammation follows, which may 
terminate in sloughing or suppuration, and finally septicaemia. 

Symjptomatology. — The symptoms are pain following the injury, 
and then a feeling of fullness, heat, and sometimes throbbing. In 
one case that came under my observation the pressure w^as sufficient 
to prevent urination, and it was very difficult to pass the catheter. 
The attention of the patient being directed to the location of the 
injury, the swelling is discovered by the touch. 

Physical Signs. — The physical signs vary in the different stages 
of the disease. At first, the tumor is elastic and like a local oedema, 
except that it does not pit on pressure. After the blood ha^ coagTi- 



90 DISEASES OF WOMEK 

lated tlie parts are denser and slightly irregular, or slightly nodu- 
lar ; discoloration of the skin occurs in twenty-four hours, or less. 
CEdema of the skin also appears. 

Diagnosis. — In regard to the diagnosis, it may be said that 
pudendal hsematocele can hardly be confonnded with any of the 
diseases of the pudendum, except pudendal hernia, and the mode of 
development and piiysical signs of the two affections are so unlike 
that the differentiation is easy. 

Causation. — The causes of pudendal liaBmatocele are predispos- 
ing and exciting. Yaricose conditions of the vessels, degeneration 
of the vessel-walls, aud marked engorgement from any cause which 
interrupts the venous circulation, render the vessels more liable to 
rupture when subjected to any injury. 

Pregnancy predisposes to rupture of the pudendal vessels, and 
labor is one of the most prominent of the exciting causes, but the 
present discussion of this affection is limited to causes occurring in 
the non-puerperal state. The reader will lind a very full account of 
this affection, as it occurs in labor, in a monograph by Prof. Fordyce 
Barker. 

In regard to the exciting causes of the affection, it may be said, 
in brief, that they are alwaj^s traumatic. Direct blows are the 
usual means by which the vessels are ruptured ; indirect injuries — 
from a fall, for instance — might produce rupture of the pudendal 
vessels, but I have not seen any cases in which the injury was 
caused in that way. 

Treatment. — When the patient is seen immediately, and while 
haemorrhage is still going on, an effort may be made to arrest the 
bleeding by pressure ; but if this fails after a short trial, it is best to 
lay the parts open, and secure the bleeding vessels in the way already 
described. This is quite an important operation, and requires that 
the patient should be anaesthetized, but the results fully justify the 
means. The advantages of this treatment are threefold : the bleed- 
ing is controlled effectually, and in the safest way, providing the 
surgeon is called while the bleeding is still going on ; the extent of 
inflammatory action is greatly lessened or wholly avoided ; and the 
dangers of septicaemia are guarded against by clearing out the blood- 
clots and securing free drainage. The rule is, however, that the 
surgeon is not called until the stage of bleeding is past ; it is then 
well to wait till the patient has recovered from the loss of blood, and 
reaction from the shock, if there has been any, has set in, and then 
lay open the hsematocele, turn out the clots, tie any vessels that may 
bleed, secure free drainage, and use ordinary surgical dressingc I 



DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 91 

am sure tliat tins course of treatment is tlie best, being by far the 
safest in guarding against fatal septicaemia, and securing a more 
prompt convalescence, with infinitely less danger to the tissues of 
the pudendum. 

ILLUSTRATIVE CASE. 

Pudendal Haematoma. — A dissipated woman, about forty years of 
age, was brought into the Long Island College Hospital, after having 
received a brutal beating from her husband. She had a number of 
bruises about her head and face, and complained of pain in the puden- 
dum. On examination, an enormous swelling was found in the region 
of the right labium. Pressure w^as made by means of bandages, and 
the swelling, due, no doubt, to haemorrhage, was controlled so that 
it did not increase. She had considerable fever and depression from 
her injuries, but was rallied by means of stimulants and quinine. 
At the end of forty-eight hours after her admission the ecchymosis 
was so marked, and pressure upon the tissues so great, that slough- 
ing was apprehended ; even if that should not take place, the exten- 
sive inflammation and suppuration, which necessarily must follow, 
would have placed the patient's life in great danger from septicsemia, 
and made convalescence, at least, very tedious. 

It was therefore decided to operate, which was done as follows: 
An incision about four inches long was made on the inner side of 
the tumor with the thermo-cautery knife. Proceeding slowly with 
the instrument at a dull-red heat, no haemorrhage was excited by 
the incision. The clot, a very large one, was turned out, and, just 
as soon as the pressure was removed, bleeding started at several 
points in the deeper portion of the wound. The bleeding vessels 
were caught up by compression-forceps and ligated, and the general 
oozing which kept up was controlled by the cautery. The wound 
was then packed with lint, which was held in place by a bandage ; 
the dressing was changed night and morning, the quantity of lint 
being reduced as the cavity contracted. 

She made an excellent recovery, and left the hospital in two 
weeks from the time of the operation. 

Hernia of the Pudendum. — Two varieties of hernia may occur in 
the vulva — one known as anterior-labial, and the other as poste- 
rior-labial. The former, which is sometimes described as inguinal 
labial hernia, consists in the passage of the dislocated organ by the 
side of the round ligament into the labia majora. The sac may con- 
tain intestine, omentum, ovary. Fallopian tube, or uterus. AYinckel 
found six cases of this variety of hernia in 5,000 private patients ex- 
amined by him ; in one case an ovary was found in the left side ; 



92 DISEASES OF WOMEN. 

in a second, each ovary in a hernial sac ; in a third, the uterus ; and 
in a fourth, the pregnant uterus. 

The second variety, known also as vagino-labial hernia, occurs 
much less frequently. Winckel has seen but two cases, and says that 
the hernia passes down in front of the broad ligament into an open- 
ing in the pelvic fascia and levator ani, and appears at the posterior 
extremity of one of the labia majora. 

Diagnosis, — This is not difficult, if due caution and care be ex- 
ercised. If the patient bears down, the size of the tumor will be 
increased. If she be placed in the knee-chest position, the hernia 
can be readily reduced, going back with a gurgling sound. When 
she assumes an upright position, the reduced tumor will again 
return. 

Treatment — This consists in reducing the hernia, and retaining 
the organ in place by means of a properly-applied truss. 

Vaginal Enterocele. — This is a form of hernia in which the intes- 
tines descend into the pelvic cavity, and may pass down either in 
front of or behind one of the broad ligaments. 

The hernia is usually composed of small intestine alone, though 
it may contain omentum alone, or both intestine and omentum to- 
gether. Cases have been recorded in which the large intestine came 
down instead of the small one. 

Yaginal enterocele is usually explained in the following manner : 
The intestine, having found its way into Douglas's cul-de-sao, pushes 
it downward, and gradually causes the vagina to bulge inward. This 
may increase to such a degree that, finally, the tumor may appear at 
the vulva and even protrude from it. 

Diagnosis. — This is not difficult if the examination is made with 
care, though serious errors have been made by surgeons, the tumor 
being considered an abscess, and opened by the knife. 

A vaginal enterocele may be recognized by the following char- 
acteristics : It becomes smaller on pressure ; increases in size when 
the patient coughs or bears down ; is resonant on percussion — though, 
if the contents are omentum, this sign would not be present — and is 
easily returned if the patient be placed in the knee-chest position. 
It may be mistaken for an abscess, a prolapsus of the vagina, an 
ovarian cyst, or a dropsy of the Fallopian tubes. 

Causation. — Parturition is considered as the most common cause 
of the hernia, the intestines being pressed down against the relaxed 
pelvic tissues by the expulsive pain of labor. When occurring in 
nulliparous patients, it is usually due to falls or to violent straining 
efforts. 



DISEASES OF THE EXTERNAL ORGANS OF GENERATIOiT. 93 

Treatment. — Inasmucli as the sac of this variety of liemia is not 
liable to constriction, strangulation rarely occurs. The tumor will 
disappear if the patient is placed in the knee-chest position, and its 
retention may usually be accomplished by a pessary that will keep 
the vaginal wall tense. This will at least prevent the protrusion of 
the hernia from the vulva, though it is doubtful if any treatment 
will prevent entirely the entrance of the intestines into the pelvic 
cavity. The existence of this hernia should be borne in mind in 
case the patient becomes pregnant, for under such circumstances 
labor is often impeded by the enterocele, which, coming down in 
advance of the presenting part, offers a serious obstacle to its progress. 

Hydrocele of the Round Ligament. — In order to understand the 
condition which is present in hydrocele, it is necessary to recall the 
anatomical relations of the round ligaments and the labia majora. 

The labia, it will be remembered, are the analogues of the male 
scrotum, and the round ligament of the spermatic cord. These liga- 
ments terminate in the labia majora, and are covered by an offshoot 
from the periton£eum, the increased serous secretion formed by this 
membrane constituting hydrocele. 

Although the peritoneal sac does not ordinarily extend into the 
inguinal canal, still it may do so, and intestine or an ovary may en- 
ter this pouch. Hydrocele of the round ligament is liable to be 
confounded with hernia. The tumor will be translucent if it be 
hydrocele, and this, together with the history, will be sufficient to 
make the diagnosis. An aspirator needle may be employed to make 
the diagnosis more certain. It is an exceedingly rare disease, and 
one that I have never seen. 

Treatment. — The fluid contents of the sac should be withdrawn 
by aspiration, and tincture of iodine injected. 

Hypersesthesia of the Vulva. — This disease, as the name implies, 
is characterized by a supersensitiveness of the vulva. Pruritus is 
absent, and on examination of the parts affected no redness or other 
external manifestation of the disease is visible. When, however, 
the examining finger comes in contact with the hyperaesthetic pai't, 
the patient complains of pain, which is sometimes so great as to 
cause her to cry out. Indeed, the sensitiveness is occasionally so 
exa_2:gerated as to keep the patient from consulting her physician 
until it becomes absolutely intolerable. Sexual intercourse is equally 
painful, and becomes in aggravated cases impossible. 

This affection must not be confounded with vaginismus, or with 
other conditions of increased sensitiveness of the \ailva due to in- 
flammatorv conditions. 



94 DISEASES OF WOMEN". 

Causation. — The causes which produce this hypersesthetic con- 
dition of the vulva, when not due to inflammation or the pressure 
of urethral tumors, are difiicult to recognize. At the menopause 
the aiFection seems more likely to occur than at any other period of 
life, and women of weak mental and physical powers are more often 
its subjects than those who are strong both in mind and body. 

Treatment. — Various methods of treatment have been suggested, 
but so far as my own experience is concerned they have been in 
most instances unsatisfactory. The sensitive tissue has been dis- 
sected off and relief obtained for a time, the hyperassthesia return- 
ing, however, as before the operation. Nitric acid has been ap- 
plied, but without a cure resulting. The best that we can probably 
do for our patients is to build them up with tonics and nutritious 
food, and, if possible, to send them away so that they can have the 
benefit of a change of air and of scene, and at the same time be re- 
moved from the irritation of sexaal intercourse, which of necessity 
aggravates and perpetuates the hypersesthesia. I have repeatedly 
been able to relieve the hypersesthesia, temporarily, by the applica- 
tion of cocaine in a four-per-cent solution. This will also be found 
useful when making examinations in cases of sensitive vulva, or in 
passing the sound into a sensitive uterus. 

Pruritus Vulvae. — This condition is a symptom rather than a dis- 
ease in and of itself, and yet it is such a prominent one in many cases 
as to justify its description as an inde|)endent affection. 

Pathology. — Pruritus consists essentially in an irritable condition 
of the nerves of the part affected. Although this is ordinarily the 
vulva, it may be and often is the vagina and the anus, and even the 
integument of the abdomen and thighs may be involved. 

Symptomatology. — The patient notices an itching of the parts 
affected, which is at first relieved by scratching or rubbing, but later 
this relief is but temporary, and the friction aggravates the original 
trouble, until an eruption of an irritating nature appears, from which 
at a still later period there is an exudation, which, by the nails used 
in scratching, or in other ways, is carried to other portions of the 
body, and seems by its irritant nature to excite a similar trouble 
there. The itching and the burning sensations become at times in- 
tolerable, and the patient is debarred from the society of her friends. 
In some instances the annoyance and suffering are increased at night, 
and in order to obtain sleep hypnotics have to be administered. 

Physical Signs. — It is more than probable that pruritus is always 
secondary to some other trouble. A due appreciation of this fact is 
necessary for the institution of proper treatment, as, if it is lost sight 



DISEASES OF THE EXTERNAL ORGAN'S OF GENERATIOJ^. 95 

of, and that which is in reality only a symptom is regarded as a disease, 
the prm-itns will continue almost indehnitely, and in its chronic form 
will resist all remedial measures. Leucorrhoea is very commonly as- 
sociated with pruritus, and appears to stand in a causative relation 
thereto. Other irritating fluids may also produce the same result. 
Of these the most common are diabetic urine and the discharges 
from an ulcerating cancer of the uterus. The leucorrhoeal discharge 
which is most likely to produce pruritus is that from a uterus which 
is the seat of endometritis, either cervical or corporeal. 

The presence of parasites may also account for the existence of 
pruritus. 

Treatment. — From the principle already laid down that pruritus 
is to be regarded as a symptom of some pre-existing disease, the de- 
tection of this disease will first demand attention, and when discov- 
ered treatment appropriate thereto should follow. If there be an 
endometritis, the discharge from which irritates the vulva or other 
parts, and causes pruritus, the inflammation should be treated as 
advised elsewhere. 

A pledget of absorbent cotton placed against the os, to receive 
the discharge, will be of great benefit ; this should, of course, be 
renewed sufficiently often. Yaginal douches containing acetate of 
lead or carbolic acid will often give great relief. Subnitrate of bis- 
muth may be dusted on to prevent friction of the labia against each 
other ; this sometimes relieves the pruritus. I have found this to 
be one of the best local applications in the pruritus caused by diabe- 
tes ; in such cases I direct the patient to keep the urine from coming 
in contact with the parts, as far as possible, when urinating, and to 
dry the pudendum and dust it over with subnitrate of bismuth. By 
adding an equal quantity of prepared chalk to the bismuth, it makes 
a powder that is more easily used. 

Yery satisfactory results can be obtained in the management of 
cases where the pruritus is caused by some appreciable disease of the 
organs. The greatest difficulties are experienced, however, in the 
treatment of that form of pruritus which occurs without any lesion 
of structure or accompanying affections to account for it. That 
there are some morbid changes in the tissues, in the violent pruritus 
which is experienced, is no doubt true, but so far they have not been 
demonstrated by pathologists, and hence the majority of authoi-s con- 
sider that this aifection is a neurosis. 

In the majority of cases of this kind that have come under my 
observation, the skin has been bleached, in spots appearing whiter 
than the normal skin. It has also lost the normal elasticitv. To the 



96 DISEASES OF WOMEN. 

touch it seems harder and less flexible, but what these changes are, 
and whether thej are related to the pruritus, are questions which 
have not yet been answered. 

The pathology and causation of this affection are both obscure, 
and the treatment is equally unsatisfactory. Many of these cases 
prove to be incurable, and in some it is not possible to give the patient 
complete relief by any local treatment. This has led to the use of a 
great variety of agents, but none of them has proved to be reliable 
in all cases. The remedies that have given the best results in ray 
practice are bichloride of mercury and emulsion of bitter almonds, 
one grain to tlie ounce ; this is applied to the parts affected twice a 
day. A powder composed of one grain of morphine to two grains 
of chalk, to be applied night and morning ; equal parts of tincture 
of opium, iodine, and aconite, and eight per cent of carbolic acid, 
applied once a day — all of these have been tried, and each one has 
proved serviceable to some extent, but there are cases which resist 
all these remedies. 

The bichloride of mercury mixture, used alone, has been of the 
most service in the largest number of cases. Where it fails, I have 
used a solution of iodoform in ether ; this is applied by means of an 
atomizer, and by using strong air-pressure the solution is forced into 
all the folds of the mucous membrane ; the ether soon evaporates, and 
leaves a fine coating of the iodoform over the whole surface. This 
nearly always relieves, and if applied frequently is curative in some 
cases. I have also used carbolic acid and tincture of iodine, equal 
parts, and this nearly always gives relief for a day or more. In the 
following case this application relieved the pruritus permanently : 

The patient had passed the menopause, and, although she had 
not borne children, her health had always been good. Dr. Fordyce 
Barker, whom she consulted, sent her to me, telling her at the same 
time that I could not cure her, but would give her as much relief as 
possible. I tried the usual remedies, with no benelii;. I then used 
the carbolic acid and iodine, but found it difficult to apply to all the 
irregularities of the surface. I applied it with the atomizer, using 
a high pressure, so that the solution was forced into the tissues, and 
a deeper effect obtained than I had expected. The result of this 
was, that the patient suffered greatly. The first effect was sharp 
pain, followed very soon by relief from the itching, and numbness 
of the parts ; in short, the ansesthetic effect of the carbolic acid was 
obtained in a marked degree. Following this there were great irri- 
tation and pain ; the epithelial layers of the skin and mucous mem- 
brane came off as if they had been blistered, and there was much 



DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 97 

sensitiveness. During this, while the patient was suffering the 
most pain, she said that it caused far less suffering than the itching. 
When she recovered from the treatment the itching did not return 
for several weeks, and then only in a slight degree. I made the 
same application once again to several spots where there was severe 
itching, being careful not to cover more than a very small area. It 
was not necessary to apply the remedy the third time. 

She completely recovered, and remained well for one year at 
least ; and I presume she has had no relapse, as I should probably 
have heard from her if she had. 

Eruptions of the Vulva. — The vulva may be the seat of eczema, 
either acute or chronic, herpes, prurigo, erysipelas, and diphtheria. 

Eczema here as elsewhere consists of vesicles, or a somewhat 
reddened skin, from which a serous fluid escapes. This dries, and 
oftentimes a thick crust forms, under which pus may accumulate. 
If the attack does not become chronic, this crust falls off in one or 
two weeks, exposing a new and tender epidermis beneath. If, on 
the other hand, the affection becomes chronic, the tissues become 
thickened by exudation, and at the same time dry, and lose their 
suppleness. This condition is very liable to extend to the thighs 
and to the integument about the mons veneris and anus. 

In herpes, vesicles are also present, but they are not accompanied 
by any redness or inflammation of the surrounding tissues. These 
vesicles may rupture and scales result, but, like herpetic eruptions 
on the lips, they are of short duration, and soon disappear. 

In prurigo, small papules are seen on the affected parts. Kiihn 
describes them as having a small, dark spot in the center, which is 
depressed, and containing a tenacious, reddish, gland-like mass at- 
tached to the bottom of the papilla. 

Treatment. — In the acute form of eczema, in which there is free 
transudation of serum, I use subnitrate of bismuth or powdered soap- 
stone, with three to five per cent of carbolic acid. When the parts 
are dry, I employ oxide-of-zinc ointment, carbolic-acid ointment, or 
glycerine and borax. In chronic forms of eczema, apj)lications of 
nitrate of silver, twenty grains to the ounce of water, may be made. 
This may be done once or twice a week. The herpetic eruption 
will disappear without treatment, and the only indication is to keep 
the affected parts protected from friction. 

Prurigo may be cured, according to Kiihn, by removing these 
tenacious masses which have been described as situated at the bottom 
of the papillae. 

The vulva is sometimes the seat of erysipelatous and diphtheritic 



98 DISEASES OF WOMEN. 

inflammation. Erysipelas is rare in adult life, and indeed may be 
said to occur most frequently in the very earliest infancy. In its 
local treatment sugar-of-lead lotions may be applied, and internally 
tonics and stimulants. The prescription which has given me the 
most satisfaction is as follows : Borax, one drachm ; tincture of 
opium, one ounce; glycerin, three drachms; and water, three 
ounces. The parts should be kept constantly moistened with this. 

Diphtheria of the vulva occurs in some cases when the exudation 
exists in the pharynx or larynx, and rarely as an independent disease. 
Its treatment is constitutional. 

E'oma, or gangrene of the vulva, is perhaps best considered in 
connection with the eruptive diseases. The first indication is a 
swelling of one of the labia majora, which becomes of a grayish- 
green color, followed by vesicles; the color changes to brown, and 
gangrene rapidly sets in. 

Causation. — J^oma occurs in children whose general health is 
poor, either from iusufiicient and improper food, or from having lived 
in squalid tenement-houses ; or, indeed, from both combined. It 
may also occur as a complication of one of the contagious diseases — 
scarlet fever, measles, or small-pox. 

The prognosis in noma is very grave. 

Treatment. — This should be directed to sustaining the failing 
powers of the patient. For this purpose quinine, iron, and stimu- 
lants should be freely administered, and antiseptic dressings applied 
to the affected parts. It has been recommended to excise the gan- 
grenous tissue, and to apply the actual cautery to the underlying 
parts. 



CHAPTEK yi. 



DISEASES OF THE VAGINA. 



Anatomy of the Vagina. — The vagina is the continuation of the 
genital tract from the uterus to the vulva. It is curved to coincide 
with the axis of the pelvic excavation ; this, to some extent, renders 
it mnch shorter in front than behind. The anterior wall is about 
two inches long, while the posterior is nearly twice that length. The 
anterior wall is further shortened 
by the cervix uteri which joins 
the vagina much nearer to the vul- 
va in front. 

Fig. 59 shows the comparative 
length of the vagina in front and 
behind. 

The vagina is attached above 
to the cervix, about midway be- 
tween the body of the uterus and 
the termination of the cervix uteri. 
Below, it unites with the floor of 
the pelvis and the structures which 
form the vulva. Anteriorly, it is 
united to the bladder and urethra ; 

to the former loosely, and to the latter so iirmly 
that it is almost impossible to separate these 
structures even by dissection. Posteriorly, the 
vagina and rectum are united and form the recto- 
vaginal septum. Below, they are separated by 
the sphincter-ani and tranversns-perinei muscles 
and cellular tissue. Fig. 60 shows the triangle 
formed by the bifurcation of the two canals and 
T- ar^ ^^'m • , tlic dlvldcd musclcs between them. 

Fig. 60. — Tnanp;u]ar mi • • 

shape of perineal body. The vesico-vagiual septum is the most resist- 




FiG. 59. 



Length of vagina, less in front 
than behind. 




100 DISEASES OF WOMEN. 

ant portion of the vaginal walls, and, when put npon the stretcli, 
feels like a cord Ijing beneath the mucous layer ; this is called ttie 
anterior column of the vagina. 

The vaginal walls are composed of three coats — an external, mid- 
dle, and internal ; the external consists of fibrous, elastic, and areo- 
lar tissue : the middle of un striped muscular fiber ; and the inter- 
nal of mucous membrane. The muscular coat is continuous mth the 
middle coat of the uterus, and the two are alike in structure, and in 
the fact that thej both undergo extraordinary hypertrophy during 
utero-gestation. The mucous membrane of the vagina is continuous 
with the endometrium, but differs from the latter in stracture to a 
marked extent. It is arranged in transverse folds, which are most 
prominent anteriorly, and is studded with papilla3 and covered with 
pavement epithelium. In general structure the mucous membrane 
of the vagina resembles very much the skin. This is noticeable in 
cases of prolapsus, in which the membrane, by being exposed, be- 
comes dry and its epithelium hardened. 

The structure of this membrane is like the skin to some extent — 
its secretion is serous and of acid reaction. There has been some 
discussion among anatomists regarding the presence or absence of 
muciparous glands in this vaginal membrane. The fact is that they 
are abundant in the lower third, but nearly absent in the middle and 
upper thii'ds. 

The vagina is developed like the uterus, from Mailer's ducts, and 
is hable to malformations from arrest or defects of development. 

Malfonnations of the Vagina. — Imperforate hymen has been al- 
ready discussed under the head of menstrual disorders due to mal- 
formations of the sexual organs generally. 

Double vagina usually occurs in connection with double uterus, 
and in such cases no harm to the patient is likely to result. 

Perpetuation of the septum between the most dependent por- 
tions of Miiller's ducts has been found. In one patient who came 
under my observation a tliick septum extended from just within the 
hymen upward about an inch and three quarters. This malforma- 
tion gave rise to no symptoms, and was not recognized until the 
birth of her first child, when the attending physician found that it 
caused some obstruction to deliver3\ I examined the case about two 
months after her confinement and found this septum, about a quarter 
of an inch thick and quite resistant. It was divided by two incis- 
ions parallel to the axis of the vagina, and about three quarters of 
an inch apart. The strip thus removed was not the whole of the 
septum, but it was sufficient, as the ends remained contracted. The 



DISEASES OF THE VAGINA. 101 

divided edges were brought together with sutures, and healing took 
place very promptly. 

Imperforate Vagina. — Absence of the vagina has been described 
as one of the malformations, but it is doubtful if there is not in 
these cases a rudiment of vagina, which is imperforate, and hence 
absent to all intents and purposes. In the most complete case of the 
kind that I have seen the rectum and bladder were near together. 
With the finger in the rectum, and a large sound in the bladder, a 
rather dense cord running upward from the vulva could be felt. 
The uterus was also rudimentary, and although the patient had 
passed the period of puberty, and had the outward characteristics 
of her sex, she had never menstruated. This was evident from the 
absence of menstrual flow in the uterus and Fallopian tubes. . 

In cases like this nothing can be gained by treatment. So long 
as there is no excessive menstruation, which would endanger the life 
of the patient, there should be no interference. 

Atresia of the Vagina. — This is the more common affection. It 
may be either complete or partial, congenital or acquired. 

In the congenital form the atresia may extend the whole length 
of the vagina, and that condition is generally associated with an un- 
developed uterus. The incomplete, or partial, atresia is usually at 
the lower third, but it may occur at the upper or middle portion of 
the vagina. 

Congenital atresia occurs under two different conditions. The 
one is associated with defective development of the uterus or 
ovaries, or both, sufficient to prevent menstruation altogether. In 
the other, menstruation takes place, but the flow being obstructed, 
accumulation occurs in the uterus and sometimes in the Fallopian 
tubes. These differing conditions require different management. I 
will therefore consider them separately. 

Atresia of the vagina, with defective development of the uterus 
and ovaries, is only of interest with reference to the diagnosis. Noth- 
ing can be done, nor is there any active demand for treatment. The 
patient does not suffer, as a rule, except from the consciousness of 
her deformity, which would only cause mental distress in case she 
intended to get married. 

Two such ca^es have come under my observation. The most 
typical one was of a good family, strong, but inclined to flesh. She 
did not change much in general appearance at puberty, but main- 
tained considerable of the masculine type. She never showed the 
slightest disposition to menstruate. She was asked by a worthy 
man to marry, but she was afraid to do so without advice, kno^dng 



102 DISEASES OF WOMEN^. 

that she was " unUke other women." She sought advice, and on ex- 
amination there was found atresia of the vagina, and apparently the 
uterus and ovaries were rudimentary. E^othing could be done to 
help her. She took up nursing as a profession, and has succeeded 
remarkably well. This case is briefly given in order that this variety 
may be contrasted with the next form. 

Atresia associated with fully developed uterus and ovaries may 
be complete or incomplete. Usually, there is no notice taken of the 
deformity until puberty arrives, unless the attention of the mother 
or physician is directed to the pelvic organs for some other reason. 
There are no symptoms until puberty. Then the patient, after hav- 
ing undergone the changes characteristic of the period, has all the 
symptoms of menstruation without the flow. 

The symptoms, or menstrual molimen, as they are called in their 
totahty, are more marked than in normal menstruation, and great 
pain, fullness, and tenesmus, come on during the period. The first 
effort at menstruation is not usually attended with such severe suf- 
fering, but each succeeding period is w^orse, and very soon the evi- 
dences of the accumulated fluid become tangible. 

Physical Signs. — Inspection of the parts shows a complete closure 
of the vulva. Combined touch with a straight sound in the bladder 
and a finger in the rectum, reveals the fact that in absence of the 
vagina the rectal and vesical walls come together, and are thin and 
elastic. If the vagina is present, but closed, it is felt between the 
sound and finger as a firm cord. When the uterus is distended with 
menstrual fluid, the accumulation causes a tumor, w^hich is elastic and 
obscurely fluctuating. The signs of partial atresia differ according 
to the location of the occlusion. When the atresia is in the upper 
third of the vagina the lower portion of the canal ends in a cul-de-sac. 
If the atresia is at the lower third, the obstruction is found below, and, 
by means of the sound in the bladder and the finger in the rectum, 
the upper portion of the vagina is found distended with menstrual fluid. 

Causation. — Congenital atresia is produced by some arrest of 
development or disease during embryonic life. When it is acquired 
between birth and puberty, it is usually due to acute inflammation 
occurring in connection with some constitutional disease, such as 
scarlatina, diphtheria, or measles. 

Gangrenous vulvitis and vaginitis, which may occur in the course 
of any of the above-named diseases, may also terminate in atresia. 
I have seen two cases of partial atresia, caused by some acute inflam- 
mation during the course of typhoid fever, occurring near the period 
of puberty. 



DISEASES OF THE YAGINA. 103 

In the cases whicli have been acquired after puberty and child- 
bearing, one was a soldier's wife, who was confined of her first child 
at a military post on the frontier. Her labor was of three days' 
duration, and she was finally delivered by craniotomy ; there was 
subsequent sloughing of the vaginal walls, and consequent atresia. 

Another case of partial atresia was caused by amputation of the 
cervix for cancer. There was at the time of the operation deep cau- 
terization of the vaginal walls, which resulted in atresia. One other 
case was caused by the accidental use of pure carbolic acid, as a vag- 
inal injection. In this case the adhesions of the vaginal walls were 
not very firm, and the canal was restored by operation, but there 
was much trouble experienced in preventing the recurrence of the 
atresia — a constant tendency to which remained. 

Prognosis. — In complete atresia there is great difficulty in the 
operation for its relief, and a constant tendency to contraction of 
the parts ; hence, the hope of complete recovery is, to say the least, 
very limited. 

Treatment. — The indications are to restore the vagina by surgical 
means. This is a difficult procedure, and one that is not very suc- 
cessful in all cases. The difficulties in the operation, and the ulti- 
mate success, depend upon whether the atresia is partial or complete. 
If the portion of the vagina which is closed is limited to a third of 
the whole canal, reasonable hope of success may be entertained, but 
I doubt if the vagina was ever fully restored and maintained when 
complete atresia existed. 

When there is associated with the atresia imperfect development 
of the uterus and ovaries, and there is no tendency to menstruation, 
treatment is not indicated. Such malformed subjects often live quite 
comfortable and useful lives. 

There is another class of cases, already referred to in treating of 
absence of the menstrual function, in which the uterus and vagina 
are rudimentary, but the ovaries are well developed. In these there 
is a recurring menstrual molimen, and the general nervous system 
may become greatly deranged. Ovaro-epilepsy may occur under 
these conditions. The removal of the ovaries might become neces- 
sary in such cases in order to arrest the inolination to menstruation, 
and relieve the constitutional disturbance caused by such unsuccessful 
efforts. 

The following is a description of Dupuytren's operation for 
atresia of the vagina, as described by Courty, with the modifications 
which M. Puesch has added, which I quote from the work of Dr. 
Thomas : 



104: DISEASES OF WOMEN. 

" After having arranged the woman in a convenient position, the 
bladder is emptied bj means of a male catheter, which is given to 
an assistant, who holds it turned upward. It is not removed during 
the operation, except where the obliquity of the part would render 
it troublesome. The index-finger of the left hand is then carried 
into the intestine as far as possible, in order to serve as a guide for 
the bistoury and at the same time as a protection to the rectum. 
After these preliminary steps the operator, placed between the thighs 
of the patient, makes a transverse incision at the center of the obsta- 
cle, or in the vulvar orifice, if the vagina is completely wanting ; if 
the cellular tissue is lax, he can tear with his finger, the sound, or 
the handle of the bistoury the vesical and rectal walls till he reaches 
the tumor ; if it is tense or too resistant, the surgeon dissects by 
gentle efforts, separating the tissues with the handle or the finger 
rather than cutting them, and, if it be necessary, breaking them down 
at the edges with a button bistoury. In each case he proceeds slowly 
and carefully, stopping from time to time to examine with the finger 
and be certain at what distance those organs are situated which it is 
necessary to avoid. When the canal which has been reopened will 
admit the index-finger easily, and when a more distinct perception 
of fluctuation announces the proximity of the sanguineous collection, 
the operator is warranted in plunging a trocar into this, and the 
pouring out of a sirupy, brown liquid, like the lees of wine, will 
show that the end has been reached. The pressure upon the uterus 
is then stopped, a large part of the fluid is allowed to flow away 
through the canula, and then, substituting for this instrument a per- 
forated sound, the operator increases the size of the opening by nu- 
merous incisions upon its sides, and thus renders certain the final 
result. Afterward he carries a gum-elastic sound into the uterine 
cavity, and throws through this, but with very httle force, several 
injections of warm water. The dressing having been finished, the 
parts are sponged and dried, and the patient is placed in bed, pro- 
tected with cloths, so as to prevent the bedding from being soiled 
by the mucous and sanguinolent discharges which flow^ during the 
first days." 

To keep the canal open after this operation is exceedingly difii- 
cult ; all surgeons testify to this fact. Many things have been tried 
to accomplish this object, but the best is the glass plug or dilator of 
Sims (Fig. 61). In one case — the case of acquired atresia referred 
to under the head of causation — I found that the glass instrument 
caused much pain, and I used elm- bark cut in fine strips, made into 
a roll of suitable size, and moistened with carboh'zed water. This 



DISEASES OF THE VAGINA^ 



105 



was removed daily, and, as it expanded after being introduced, it 
answered in that case very well. 

The tendency in all these cases is to contraction and return of 
the atresia ; in fact, I 
have never seen a 
case of complete atre- 
sia permanently cur- 
ed. In view of all 
these, I have been 
guided in practice 
by the valuable sug- 
gestions of West. 




Fig. 61.— Sims's vaginal dilator. 



The following is from his work on " Diseases of Women," page 34 : 
" The operation for atresia is performed by the bistoury or 
guarded bistoury, or Pouteau's trocar. The bistoury is to be gener- 
ally preferred. Pouteau's trocar is resorted to when a considerable 
part of the lower vagina is absent, and the sac is punctured some- 
times pretty high up per rectum. This operation is in such cases 
preferable to vain, painful, and dangerous attempts to bore the thin 
tissues between the urethra and rectum to make and maintain a new 
vagina. Such a proceeding results only in vexation. It is far better 
for the malformed woman to discourage all hopes of maternity. The 
artificial passage into the rectum is easily kept open, and the men- 
strual fluid runs off through it." 



INFLAMMATORY AFFECTIONS OF THE VAGINA. 

Vaginitis. — The vagina is seldom if ever affected with idiopathic 
inflammation; vaginitis, therefore, always occurs as the result of 
some specific cause, or is secondary to some contiguous inflammation, 
such as endometritis. There are several varieties of vaginitis. Clas- 
sified according to the intensity and duration of the affection, there 
are the acute and chronic forms ; when classified according to the 
causation, there is a number of forms, the most important of which 
are gonorrhoeal, erythematous, sometimes called erysipelatous, and 
diphtheritic. As a rule, the inflammation is general, involving the 
whole canal ; occasionally it is circumscribed, and then it is found 
just within the vnlva, or else at the upper part. 

Pathology. — Owing to the anatomical peculiarities of the vagina 
it is not susceptible of the catarrhal form of inflammation, so com- 
mon to mucous membranes elsewhere. From the fact that the vag- 
inal mucous membrane resembles in structure the skin, and that 



106 DISEASES OF WOMEN". 

there are few mucous follicles found in it, vaginitis, in its pathology, 
is more like dermatitis than like the ordinary inflammations of mu- 
cous membranes. Congestion, transudation of serum, premature ex- 
foliation of the epithelium, and, in well-defined cases, the formation 
of pus, are the characteristic results of acute vaginitis. 

In the subacute form there is less congestion and less pus, other- 
wise the inflammatory lesions are the same. This may all be more 
briefly stated in another form, as follows : Vaginitis occurs either as 
erythematous, purulent, or exudative — never as purely catarrhal. 

The morbid appearances in these forms differ. Erythematous 
vaginitis is characterized by great capillary congestion, w^hich gives 
tlie intense redness of this form of inflammation in the first stage. 
Then, as the disease advances, there is exfoliation of the epithelium. 
Sometimes the epithelium comes off in thin flakes, resembling in 
this respect the exfoliation of the cuticle in dermatitis. This leaves 
the mucous membrane denuded of its epithelium, and gives a glazed 
appearance to the whole canal. During this time there may be a 
free serous secretion and some pus found, but these are not profuse 
in all cases. 

In purulent vaginitis the lesions are the same as already described. 
In the exudative forms the characteristic lesions are present ; the 
diphtheritic membrane as in diphtheria, the croupous in that form 
of inflammation. 

There are other forms of vaginitis mentioned by some authors, 
but they are peculiar in regard to causation, while in their pathoL 
ogy they do not differ materially from those described. 

Symjptomatology. — The symptoms in the acute form are a feeling 
of internal heat and fullness. These increase in intensity, and pain 
in the vagina and uterus come on. Yesical and rectal tenesmus are 
present in severe cases, and urination and defecation are painful. 
The urine causes violent smarting of the inflamed parts about the 
vulva with which it comes in contact. So severe is the pain in some 
cases during and after urination, that the patient resists the inclina- 
tion until the power of evacuation is lost, and there is retention. 

There are constitutional disturbances also. At first there is fever, 
and following that loss of appetite and debility. The discharge is 
profuse, and sero-puralent in character ; it causes excoriation of the 
external parts, which often extends to the Hmbs. If great cleanli- 
ness is not observed, the discharge decomposes and causes a very dis- 
agreeable odor. 

In the subacute and chronic forms of vaginitis the symptoms 
are the same in character, but less in degree ; in fact, the annoy- 



DISEASES OF THE VAGINA. 107 

ing discharge is the only symptom observed in many of these mild 
cases. 

Physical Sigiis. — By inspection of the parts when the labia are 
separated the characteristic discharge can be seen and recognized. 
It differs from that of vulvitis in being less tenacions. The mucous 
glands about the vulva give to the discharge of vulvitis a cohesive- 
ness which is not found in that of vaginitis. The use of Sims's 
speculum will show the inflamed appearance of the membrane and 
the discharge which is present. 

The anterior and lateral portions only of the walls of the vagina 
are seen through the Sims speculum, but by watching the folding 
together of the posterior and anterior walls, as the speculum is with- 
drawn, the whole canal can be thoroughly inspected. 

The difference between the signs of acute and sub-acute inflam- 
mation is simply in the intensity of the congestion, the extent of the 
canal involved, and the quantity and character of the discharge. 

To distinguish gonorrhoea! vaginitis from the non-specific forms 
the microscope alone is sufficient. When there is a question regard- 
ing the nature or the cause, specimens of the discharge should be 
examined for the gonococci. 

Causation. — There is a predisposition to vaginitis in those of 
delicate health and strumous diathesis, but it is not marked. 

Judging from my own observations, the common causes of vagi- 
nitis are gonorrhoeal virus, metritis, especially puerperal, and ery- 
thematous affections. This applies to the acute form of the affec- 
tion. 

Sub-acute and chronic vaginitis may be caused by any inflam- 
mation in the neighborhood of the canal. Dysentery, for example, 
causes vaginitis not infrequently. Diff'erent fungi have been credited 
with causing vaginitis, but this is not well settled. When it occurs 
in connection with the eruptive diseases the cause is, of course, the 
specific morbid material which produces the constitutional disease. 

Prognosis. — With proper care vaginitis can be arrested and re- 
covery secured without any permanent lesions. It is liable to re- 
cur if caused by gonorrhoea. 

Sometimes permanent damage is done to the canal when the 
vaginitis is due to any of the eruptive diseases or diplitheria. 

Treatm.ent. — In the past, treatment of vaginitis has consisted 
mainly of the frequent use of medicinal douches. The agents used, 
and the means and ways of using them, have varied greatly with 
different practitioners. Very recently a new method of treatment 
has been brought to the notice of the profession by Dr. Engelmaun, 



108 DISEASES OF WOMEN. 

of St. Louis. His method lie terms the dry treatment, which consists 
in the use of medicinal powders and medicated tampons. A number 
of years ago I tried this method, in an iniperfect and limited way, 
in the treatment of vaginitis among the insane, and obtained ex- 
perience enough to know that it is of great value. I iind even now, 
however, that while using certain agents in powdered form, and also 
the tampon, the discharge from the inflammation and the powder 
used lodge in the folds of the mucous membrane, and that it is 
necessary to use a vaginal douche occasionally in order to make the 
treatment effective. 

In acute vaginitis I employ what may be called a mixed treat- 
ment, using the medicinal agents and powder with tampon, and oc- 
casionally employing the douche in the following way : After cleans- 
ing the mucous membrane thoroughly with a douche of warm water 
and borax, a drachm to the quart, I then thoroughly apply sub- 
nitrate of bismuth and prepared chalk, equal parts, and introduce a 
tampon of borated cotton, the tampon being so arranged as to thor- 
oughly keep the vaginal walls apart ; at the end of twenty-four hours 
the tampon is removed, and any accumulation of the discharge and 
powder is thoroughly removed and the tampon replaced. At the 
end of the next twenty-four hours the tampon is removed and the 
douche of borax and water employed, and the dry treatment re- 
peated. 

In acute cases where there is much pain, and especially if due 
to specific cause, I employ iodoform in place of the bismuth. If 
the trouble does not yield promptly to this treatment I give up the 
dry dressing, and every third day apply to the entire canal, by means 
of the atomizer with strong pressure, a solution of nitrate of silver, 
one grain to the ounce, or sulphate of zinc, one half grain to the 
ounce. I find that such mild solutions, applied with considerable 
force with the atomizer, diffuse the application very thoroughly, and 
produce a far more marked effect than much stronger solutions used 
as a douche. 

The method of application or spraying the canal is as follows : 
A Sims's speculum is introduced, and when the canal is distended 
by pressure, the spray is thoroughly applied to the upper portion of 
the canal and to the antei'ior and lateral walls, and the posterior wall 
is sprayed as the speculum is gradually withdrawn. In the inter- 
vening days between these applications I employ daily, or twice a 
day, a vaginal douche of a solution of sulphate of zinc, sixty grains 
to the quart of warm water. 

In cases that can not be so carefully watched and treated, I rely 



DISEASES OF THE VAGINA, 109 

almost wholly upon tlie sulphate-of-zinc solution, used as a vaginal 
douche twice a day at first, and subsequently once a day. This an- 
swers remarkably w^ell in a great majority of cases, but there is a 
constant liability to miss a portion of the canal, especially the upper 
and posterior fornix. To overcome this, an application of the nitrate 
of silver or sulphate of zinc is to be made to these neglected parts 
once or twice a week through the speculum. 

This simple treatment is usually sufficient in all ordinary cases, 
but whenever the disease is specific in its origin, and is complicated 
with urethritis and endometritis, then these affections should be 
treated simultaneously in the ordinary way. 

If treatment is neglected or discontinued too soon, the vaginitis 
will recur in a very short time. 

Vaginismus. — Since the time when Sims first described this affec- 
tion and its treatment, it has been considered by most writers as a 
distinct affection, and is usually classed as a neurosis of the vagina 
or hymen. In all the cases which have come under my observation 
the trouble has been due either to some affection of the muscles of 
the pelvic floor, or to a hypergesthesia of the mucous membrane of 
the vagina. The former has already been spoken of in connection 
with injuries of the pelvic floor. 

Ilypersesthesia due to affections of the other pelvic organs, I have 
always looked upon as a symptom of the preceding disease of the 
uterus, rectum, or bladder. Viewing the subject from this stand- 
point, Httle need be said about it in this connection. The removal 
of the affections which give rise to it is the chief indication, and is 
generally sufficient in the way of treatment. It may be mistaken 
for anal fissure, urethral caruncle, or vaginitis. 

Occasionally, it is necessary to give relief while the treatment is 
being employed to remove the cause ; and, in those cases in which the 
cause can not be removed, efforts should be made to relieve the hyper- 
gesthesia. This can usually be done by the judicious use of cocaine. 

Neoplasms of the Vagina. — Many of the neoplasms of the vagina 
are the same in character as those found elsewhere ; as, for example, 
sarcoma, carcinoma, fibroma, and lipoma. All these are very rare. 

The diagnosis and treatment of these neoplasms are based upon 
the same principles as those which guide the practitioner in dealing 
with such affections when located in other parts of the body. 

I will, however, give a brief account of some of the more com- 
mon neoplasms of the vagina: 

Cysts of the Yagina.— These vary in size from that of a buck- 
shot to that of a child's head — one case, at least, being on record, 



110 DISEASES OF WOMEN. 

in which the tumor was of the latter size, and so seriously interfered 
with labor as to necessitate the evacuation of its contents before the 
labor could proceed. The contents of these cysts are fluid, of a color 
which may be yellowish, reddish, or greenish. JN'elaton reported a 
case in which, on analysis, the cyst contents were found to be made 
up of water, eighteen parts ; albumen, one part and a half ; and 
salts, a half -part. Microscopical examination has shown the presence 
of epithelium, piis, cholesterine, nucleated and lymphoid cells in 
these cysts. 

Winckel, who has examined these cysts with great care, states 
that their walls are made up as follows : The external surface is 
covered with the ordinary pavement epithelium of the vagina ; the 
thickness of the walls varies between one twenty-fifth and two fifths 
of an inch — the thinnest portion being formed of connective tissue 
alone, the thicker with the addition of smooth muscular fibers. The 
internal surface is usually perfectly smooth, but may show papillse 
covered with epithelium, which in the majority of cases is cylindri- 
cal, more rarely simple, or stratified pavement e23ithelium, or still 
more rarely, stratified pavement and cylindrical epithelium in the 
same cyst. 

These cysts of the vagina are caused in some cases by a closing 
and subsequent distention of the vaginal glands. They may also be 
due to dilated lymph-vessels, to oedema, and to the accumulation of 
blood after an injury. Cysts may also have their origin in Wolff's 
or Gartner's canals and in Miiller's ducts. It is probable that cysts 
of the vagina are more common than is generally supposed. Their 
recognition is not difiicult, provided that a careful inspection is made 
of the vaginal canal. Their treatment is exceedingly simple. It 
consists in emptying them by an incision through their walls. To 
prevent then* refilling, a portion of the wall may be cut out, and the 
interior of the cyst painted with the tincture of iodine. 

FiBEoiMA, Myoma, and Fibeomyoma. — These growths occur but 
rarely. Like the cysts of which I have already spoken, they vary 
very much in size ; some being so small as only to be recognized by 
the most careful examination, while others may be so large as to in- 
terfere seriously with micturition or defecation, or even to so dimin- 
ish the cahber of the pelvic canal in pregnant women as to prevent 
the delivery of the child through the natural passage, and to necessi- 
tate laparotomy. These tumors are readily recognized by their den- 
sity. If there is any doubt in the mind of the practitioner, an aspi- 
rating needle will at once exclude a cyst or an abscess. If the tumor 
attains any considerable size so as to interfere with any of the func- 



DISEASES OF THE VAGINA. Ill 

tions it should be removed, or if, tlioiigh. small, it is increasing in 
size, this would constitute sufficient indication for its removal. This 
may be done by Paquelin's cautery, if the tumor is sufficiently pedun- 
culated, or if not, it may be enucleated. 

Sarcoma. — This is so rare as to need but the simple mention. 
Its treatment would, of course, be prompt removal as soon as recog- 
nized. 

Caecin'oma. — All that I think it necessary to say on this subject 
has been said in the chapter on cancer of the uterus, to which the 
reader is referred. 



CHAPTEK YIL 



INJURIES TO THE PELVIC FLOOR FROM PAETURITI0:N" AKD OTHER 

CAUSES. 



In order to compreliend fully tlie nature of the injuries to the 
pelvic floor and their varied and important pathological relations, it 
is necessary to review briefly the anatomy and physiology of this 
structure. 

The pelvic floor, which is also known by the somewhat indefinite 
name of perinseum, comprises the tissues which together occupy the 
space between the bones of the pelvic outlet. It is composed of 
muscles, fascia, areolar and elastic tissues. The muscles, which 
are the chief element in the structure and perform its function, 
have their origin from the ischium, the pubes, and the coccyx. 

From these points they extend down- 
ward, inward, and backward to the 
median line, and are united to the 
terminal ends of the rectum and va- 
gina and to each other from the op- 
posite sides. 

The levator-ani muscle arises from 
the posterior surface of the os pubis, 
the pelvic fascia, and the spine of 
the ischium. It passes downward, 
backward, and inward, to be inserted 
at the following points : in the me- 
dian line, the walls of the vagina and 
rectum, its fellow of the opposite 
side, and the end of the coccyx. Fig. 
62 shows the position and attachment 
of this muscle. 

The transversus-perinsei muscle 
arises from the spine of the ischium, and passes across to the median 




Fig. 62. — The levator ani, seen from 
without after removal of part of 
the hip-bone (after Luschka). a, 
anal opening, with sphincter ; v, 
vagina. 



mJUIRIES TO THE PELVIC FLOOR. 



113 



line, where it joins its fellow of the opposite side. This muscle fills 
up part of the space left uncovered by the levator ani. The coccy- 
geus arises from the spine of the ischium, and is inserted into the 
side of tlie lower part of the sacrum and side and front of the coc- 
cyx. It is understood, of course, that there are two of each of the 
muscles thus far described, one on each side — although the two parts 
of the levator ani may be considered as one because they act as one 
muscle. The same may be said of the transversus-perinsei muscle. 
The bulbo - caverno- 
sus muscle can be 
most easily traced by 
taking as its origin 
the space between 
the sphincter ani and 
the orifice of the 
vagina. From this 
point its two halves 
pass upward, one on 
each side of the vagi- 
na. The upper an- 
terior end of each 
slip of muscle di- 
vides into three parts, 
which are inserted as 
follows : One into the 
lower surface of the 
corpus cavernosum of 
the clitoris, a second 
into the posterior por- 
tion of the bulb, and 




trans versus 
perinaei 



-The 



muscles of the pelvic floor (after Hart and 
Savage). 



the third unites with 
its fellow of the op- 
posite side in the mucous membrane of the vestibule ; and all of 
them are, through the medium of tendon and fascia, connected to 
the pubic bones. If this muscle is traced from above downward 
to the center of the pelvic floor, it will be seen to have an origin 
and insertion like that of the anterior fibers of the levator ani ; 
hence the bulbo-cavernosus and levator ani may be considered as 
one muscle. This view is justifiable from the fact that they also 
contract together, having a similar function. 

All of these muscles have one feature in common, and that is, 
the blending of their fibers from the opposite sides of the pelvic 



114 DISEASES OF WOMEN. 

outlet, and their attachment to the muscular walls of the lower por- 
tions of the rectum and vagina. 

The sphincter- ani muscle, which has a function pecuHarly its 
own, is closely united to all the other muscles of the pelvic floor by 
an interlacing of the muscular fibers and by tendinous and fascial 
attachments. This muscle arises from the end of the coccyx, and 
surrounds the end of the rectum in conjunction with its circular 
fibers, while some of its deeper fibers are attached to the tissues in 
the median line between the rectum and vagina. The superficial 
fibers of this muscle are circular, and attached to the integument 
like all true sphincteric muscles. 

Taking the muscles of the pelvic floor in the aggregate, they 
form one complete diaphragm of muscular tissue which fills the pel- 
vic outlet. By this arrangement the rectum and vagina are held in 
position, and their terminal ends controlled in the performance of 
their functions. The muscular attachment of the muscles and va- 
gina is in part shown by the preceding Figures 62 and 63. 

The normal elevation of the pelvic floor is illustrated by 
Fig. 64. 

This position of the pelvic floor and the relations of the rectum 
and vagina should be noted because they become changed in most 
of the injuries of this structure. 

The muscles of the pelvic floor are surrounded by the deep and 
superficial fascia, which in some parts become ligamentous in char- 
acter ; for example, the ischio-perineal ligament — that dense portion 
of the fascia which stretches from one side to the other through the 
space between the rectum and vagina. This fascial structure accom- 
panying the muscles is characteristic of all muscular structures which 
have to afford continuous sustaining power, like the muscles of the 
back, of the neck, abdomen, and thigh. 

Function. — These anatomical facts regarding the floor of the pel- 
vis suggest that its functions are to sustain the rectum and vagina, 
and to aid in their functions. The arrangement of the muscles is 
such that they close by sphincteric action the terminal ends of the 
rectum and vagina, yet also permit the distention of their orifices 
during the acts of parturition and evacuation of the rectum. When 
pressure is made downward by any body in the rectum or vagina, 
the perineal muscles act to draw the orifices of these canals upward, 
and hence supply a resisting force to the downward pressure which 
effects dilatation of the vagina and rectum. This action of the mus- 
cles in resisting downward pressure is well demonstrated during par- 
turition. When the child's head presses upon the fioor of the pel- 



INJURIES TO THE PELVIC FLOOR. 



115 



vis, the muscles, bj retraction, distend the sphincter ani to a great 
extent. The dilatation of the vagina is produced by a more passive 




Fig. 64. — Diagrammatic sagittal section of the female pelvis, r, uterus ; r, rectum ; s, 
symphysis ; p, perineal body ; b, is beneath bladder. This is the position of the 
uterus when the bladder is moderately full. 



giving way to the forces above, and yet the muscles exert a well- 
defined power in retracting that portion of the pelvic floor. This 
function of the muscles should be noted because it enters into the 
mechanism of most of the injuries to be discussed. 

This brief statement regarding the function of the pelvic floor 
embodies the essential points in its chief offices. There remains 
something to be said regarding its relations to the pelvic organs. 

Up to the present time the attention given to this subject by 
gynecologists has been almost wholly confined to laceration of the 
so-called perineal body — an injury frequently seen, but not by any 
means the only one that occurs to these parts. This concentration 
of attention on one portion of the subject has given rise to great 



116 DISEASES OF WOMEN. 

diversity of opinions regarding the function of the perinsenm and 
its relations to the displacements of the pelvic organs, one party to 
the controversy believing that the perineal body has much to do 
with sustaining the pelvic organs in position, the other holding that 
it has very little power in this respect. Without summing up at 
great length the arguments on both sides, the facts bearing on the 
practical side of the subject may be briefly stated. 

In all injuries of the pelvic floor which impau' its supporting 
function to any extent, prolapsus of the pelvic organs will follow in 
time, except in three conditions : 

1. When the injury is compensated for by the muscles (which 
still maintain their attachment to the vagina and rectum) drawing 
the remaining portion of the pelvic floor upward, forward, and 
toward the pubes, thereby closing the vaginal orifice and supporting 
the pelvic organs. 

2. Where by reason of some intra-]3elvic inflammation the organs 
have become fixed by adhesions ; and, 

3. Where the patient is abundantly supplied with adipose tissue, 
and takes very little active exercise. 

Excepting under the circumstances here named, prolapsus of the 
pelvic organs invariably occurs after important injuries of the pelvic 
floor. The displacement does not follow the injury immediately, 
but, as a rule, comes on slowly. This conclusion has been arrived at 
from a large number of clinical observations, and it helps to deflnite- 
ly settle the question regarding the value of tlie pelvic floor as a 
means of support for the pelvic organs. From these facts one 
may obtain the key to the differences of opinion which have been 
held by gynecologists regarding the functions of the pelvic floor. 
Those who believe that it plays a secondary part in maintaining the 
pelvic organs in position argue that there are anatomical structures 
which sustain the pelvic organs in place without aid from the pel- 
vic floor, and, in proof of this, point to the fact that the removal 
of the pelvic floor is not followed by displacement of the pelvic or- 
gans. This is often seen in cases in which lacerations sutflcient 
to largely impair the function of the pelvic floor have existed for 
years in women in active hfe without the occurrence of prolapsus 
of the pelvic organs. And, more than all this, it is said, prolapsus 
of the pelvic organs occurs where there is no apparent injury of 
the pelvic floor — i. e., no laceration of the peringeum. The falla- 
cies of this argument are that, although the pelvic organs are 
held in position by supports that are sufficient to resist ordinary 
taxation for a given time, they are not able to do so under ex- 



INJURIES TO THE PELVIC FLOOR. 117 

traordinary pressure for any length of time unaided by the pelvic 
floor. 

Again, the cases cited in which prolapsus does not occur while 
the perinfeum is lacerated belong to one or another of the three ex- 
ceptional states which I have already given. 

And, finally, the cases in which there is prolapsus while the pelvic 
floor appears to be uninjured are, as a rule, cases of mistaken diag- 
nosis, the floor of the pelvis being really imperfect, although not 
apparently so on examination by the sense of sight alone. Some 
observers look for a laceration of the perinseum by inspection of its 
mucous and tegumentary surfaces, and, if injury to these surfaces is 
not found, they pronounce the pelvic floor perfect, while the fact is 
that laceration of the peringeum in the median line is only one of 
many injuries of the pelvic floor which render it functionally imper- 
fect. But granting that the pelvic floor takes no part in supporting 
the pelvic organs under ordinary taxation, it certainly aids in doing 
so in case there is extraordinary downward pressure from lifting 
heavy weights, violent coughing, and the like. Again, when the 
pelvic floor is injured — say by laceration — and loses the power to 
support itself and the vagina and rectum, prolapsus, especially of the 
vagina, occurs. This causes a dragging upon the pelvic organs which 
in due time will cause them to descend. In view of these well- 
known facts, the most enthusiastic advocate of the independent sup- 
ports of the pelvic organs must admit that the pelvic floor is at least 
indirectly concerned in supporting the structures above it. 

Varieties. — The injuries of the pelvic floor usually seen in prac- 
tice are : 

1. The various degrees of laceration of the perinseum, i. e., in 
the median line of the pelvic floor. 

2. Subcutaneous separation of the muscles of the pelvic floor at 
their junction in the median line, or so-called perineal body. 

3. Laceration in the median line, and temporary loss of power in 
the remaining muscles from overdistention. 

4. Laceration of the levator-ani muscle, occurring alone or accom- 
panied by the lesions already given. 

5. Atrophy and permanent paralysis from injuries during partu- 
rition and other causes. 

6. Loss of muscular motion caused by the products of foi-mer 
inflammation. 

The first of these, laceration in the median line of the pelvic 
floor, is the injury most frequently sustained during parturition. 
Several degrees of this injury are described by authors, but in re 



118 DISEASES OF WOMEN". 

gard to the pathology and treatment there are only two which, in 
this connection, require attention : the one which extends through 
the muscles of the anterior portion of the pelvic floor — that is, from 
the vulva to the sphincter- ani muscle, and the other which extends 
through the sphincter-ani muscle and into the rectum. The former 
of these is the injury which is most frequently recognized, and is 
therefore presumed to occur most frequently, although this point is 
not yet settled. Certainly it is the least grave in its consequences if 
properly cared for, because it is the most easily remedied by surgical 
treatment. 

In its simplest form the laceration extends through the mucous 
membrane of the vagina, the integument, and the junction or union 
of the bulbo-cavernosus with the trans versus-perinsei muscle, a few 
fibers of the levator ani and the fascia, elastic and areolar tissues 
w^hich constitute the perineal body. 

When this injury is uncomplicated with laceration of the muscles 
of the pelvic floor elsewhere than at the median line, the separated 
ends of the muscles involved in the rupture still retain their union 
with the divided side of the perineal body and wath each other. This 
is very clearly shown by the fact that the bulbo-cavernosus, trans- 
versus peringei, and anterior fibers of the levator-ani muscles hold 
the separated sides of the perineal body and the posterior, uninjured 
portion of the pelvic floor upward. At the same time that the pos- 
terior portion of the pelvic floor is maintained at its normal eleva- 
tion, it is often brought forward to compensate for the loss of sup- 
port caused by the laceration (Fig. 65). This compensation does 
not occur in all cases, but usually does so unless there is damage 
done to the muscles other than at the median rupture alone. I have 
observed in some cases sufficient drawing forward to lessen the dis- 
tance between the meatus urinarius and anus very perceptibly. This 
is familiar to all who have studied the subject with a view to operat- 
ing, from the fact that, in order to estimate the depth of the lacera- 
tion, to determine how extensive the vivifying of tissue need be, it 
is necessary to retract the posterior portion of the pelvic floor with 
the finger or sound in order to press the rectum or anus backward 
into its place. This compensation prevents prolapsus of the pelvic 
organs for a long time, in some cases for many years, and is one rea- 
son why rupture of the perineal body is not always followed by pro- 
lapsus uteri. In this condition the vulva is not enlarged from dis- 
tention by the partially inverted vaginal walls, nor is the uterus 
necessarily displaced. Many such cases are seen among patients 
who seek relief for other affections, but have no symptoms which 



INJURIES TO THE PELVIC FLOOR. 



119 



can be traced to tlie laceration, except occasional pain in the scar 
tissne in tlie injured part. 

Case. — Mrs. H., aged forty, liad had six children. During her 
first labor she says she was "torn," the child weighing thirteen 




Fig. 65. — Complete laceration of the perinyeum ; anus di'awn forward ; no rectoeele. 

pounds. Of the perineal body a part of the anal sphincter alone re- 
mains ; but a little way up the posterior vaginal wall a thick, strong, 
muscular band crosses, which tightens about the examining finger 
and draws the anus forward. The uterus is in place, and there is no 
rectoeele ; nor sagging of the pelvic floor ; nor are there symptoms. 
(See Fig. 65.) 

Rupture through the sphincter ani is the most unfortunate of all 
injuries of the pelvic floor, owing to the incontinence which follows. 
The unhappy subjects of this accident are debarred from taking 



120 DISEASES OF WOMEN. 

much active exercise, and usually avoid society. Strange as it may 
appear, they do not all suffer from prolapsus of the pehdc organs; 
in fact, I think that prolapsus following this injury, to any great 
degree at least, is the exception. This is, no doubt, due to the fact 
that such patients are unable to do much walking or standing, and 
therefore the pelvic organs are not submitted to much downward 
pressure. It might be supposed that relief from this distressing con- 
dition would be sought before sufficient time had elapsed for prolap- 
sus to occur, but this is not always the case, for I have seen several 
such injuries of many years' standing, and yet there was very httle 
displacement. There is indeed very little falling of the pelvic floor 
or of its divided sides. This is accounted for by the fact that the 
laceration extends through the greater portion of the pelvic floor, 
leaving little remaining to settle downward. In most cases the two 
halves of the floor are held well up in position by the muscles which 
are attached to them. When the laceration is through the sphinc- 
ter-ani muscle only, and does not extend upward into the anterior 
wall of the rectum and the posterior wall of the vagina, there is a 
little control of the rectum still retained. 

This retaining power is sometimes favored by a band of scar tis- 
sue, which lies between the upper fibers of the divided sphincter, 
and gives a fixed point toward which the muscle can contract in an 
imperfect way. There is usually prolapsus of the mucous membrane 
of the rectum in cases of long standing, and the prolapsus is almost 
always greater if the wall of the vagina and rectum are also lacer- 
ated to any great extent. 

The second form of injury mentioned in the classification is sub- 
cutaneous separation of the muscles of the pelvic floor at their junc- 
tion in the median line, or perineal body. The mucous membrane 
of the vagina and the skin covering the perinseum remain normal, 
but the transversus-perinsei muscles are torn apart in the median 
line. The bulbo-cavernosus muscles are separated from their inser- 
tion at the center of the perinaeum, and possibly some of the fibers 
of the levator-ani muscle are also lacerated. There is, in short, a 
complete laceration of the deeper structures of the perinseum, the 
skin and mucous membrane alone remaining uninjured. The result 
of this injury is falling of the pelvic floor, and usually prolapsus of 
the pelvic organs. The function of the pelvic floor is destroyed as 
completely as in the injury first described. 

I beheve that this condition has frequently been mistaken for 
functional imperfection of the peringeum, or relaxation, as it hag 
been called. The fact is, that it is a well-defined anatomical lesion. 



INJURIES TO THE PELYIO FLOOR. 121 

wliich can be demonstrated quite easily by passing the finger into 
the vagina and pressing downward and outward. In this way the 
absence of the muscles, fascia, and connective tissue is discovered. 
It is found also by this examination that all muscular resistance is 
lost in the parts. Again, while the index-finger is in the vagina the 
parts anterior to the sphincter-ani muscle can be grasped between 
the finger and thumb, which will^show that where the perineal body 
should be there is only skin and posterior vaginal wall. There is 
still another method of examination, and, perhaps the most critical 
one — that is, to pass one index-finger into the vagina and the other 
into the rectum, when it will be found that the only resisting mus- 
cular tissue felt between the two fingers is the sphincter ani. 

These examinations by the touch are quite sufficient ; but, if fur- 
ther evidence is desired, it may be obtained by trying to excite con- 
traction of the muscles which act as a sphincter vaginae. This can 
be done by the interrupted electric current, or by irritating the labia. 
In making a vaginal examination, every one has noticed how actively 
the muscles of the pelvic floor contract and close the introitus vagi- 
nae in the normal state ; but in this injury no such contraction oc- 
curs, nor can it be produced by pricking the labia with a needle, or 
an}^ such means used to excite reflex action. 

In case the levator-ani muscle remains intact, the posterior por- 
tion of the pelvic floor remains in its normal position, except that the 
end of the rectum may be displaced backward, but it rarely is, as a 
rule, because the vagina and uterus are not prolapsed. The coun- 
terpart of this lesion is often seen in cases that have been operated 
upon with the intention of restoring the pelvic floor or perinseum, 
the operation having failed in its object. Union of the skin and 
mucous membrane is obtained, but the muscles are not united, and 
hence, although upon removing the sutures the result is pronounced 
to be perfect, and to the superficial observer appears to be so, the 
muscular function of the pelvic floor has not been restored, and the 
operation is, in fact, a complete failure. 

The third form of injury mentioned in the classification presents 
the same lesions as have been given in describing the two preceding- 
forms. There is a laceration in the median line down to the sphinc- 
ter ani, and also an overstretching of the muscles, which give rise to 
sagging of the whole pelvic floor and backward displacement of the 
rectum. In some cases, in place of overstretching there is retraction 
of the ends of the torn muscles, so that they have no further connec- 
tion with the divided sides of the perineal body or with the sphinc- 
ter ani, and hence they can no longer sustain the pelvic floor even in 
9* 



122 DISEASES OF WOMEN. 

an imperfect way, as is observed in cases of simple laceration already 
described, in which compensation is made by the muscles drawing 
the posterior portion of the pelvic floor upward and forward. Evi- 
dence of this subcutaneous overdistention or retraction of the mus- 
cles and temporary paralysis is seen in a great many cases of partu- 
rition. Every obstetrician has observed the complete relaxation of 
the pelvic floor that so frequently follows delivery, even when there 
is no laceration of the integument. There is not only loss of mus- 
cular motion, but also loss of sensation in some cases. That this re- 
laxation is due in many cases to overdistention of the muscles with- 
out solution of continuity is probable from the fact that recovery is 
so rapid and complete. Stilly in many cases the injury done to the 
muscles is sufficient to defy the natural recuperative powers, and 
remains permanent, if not relieved by surgical treatment. 

In many of the cases of this kind seen in practice the muscular 
insufficiency is doubtless caused by overdistention produced by pro- 
lapsus of the pelvic organs. As soon as the pelvic organs descend 
so as to make continuous pressure upon the pelvic floor, the muscles 
(impaired by the laceration in the median line) gradually give way, 
and Anally lose their contractile power, either temporarily or perma- 
nently, according to the length of time that the prolapsus has ex- 
isted. It follows, then, that it is only when sagging of the pelvic 
floor is seen before any prolapsus of the pelvic organs has taken place 
that we can reasonably infer that the muscles were impaired at the 
time that the laceration occurred, and that the injury was more ex- 
tensive than the mere separation at the median line. 

The fourth injury is laceration of the levator-ani muscle with or 
without being accompanied with the injuries which have been de- 
scribed already. 

This is the most extensive injury which occurs, and is one of the 
most disastrous of all in its consequences ; and what gives it greater 
importance is the fact that it is not, so far as I know, commonly men- 
tioned in our literature. I am satisfied that this injury to the pelvic 
floor occurs frequently, but, fortunately, recovery occurs many times 
unaided by any special treatment. Still, there are many cases in which 
the injury is permanent, and can not be relieved by any treatment 
known at the present time. This condition may be associated with 
complete laceration in the median line, but usually is not. I pre- 
sume that the subcutaneous laceration of the muscles saves the super- 
ficial structures of the perineal body. "When there is no laceration 
in the median line the tissues between the rectum and vagina appear 
to be normal ; at least the distance from the anus to the posterior 



INJDKIES TO THE PELVIC FLOOR. 



123 



commissure of the yagina is normal, but there is loss of contractile 
power in the parts. The whole pelvic floor, including the rectum, 
vagina, and lower part of the labia, projects downward below its 
normal elevation. This suggests the thought that subcutaneous lacer- 
ation of the transversus peringei generally takes place also, when the 
levator ani is injured. 

Fig. 6() shows the downward displacement resulting from the 
injury to the muscles. This displacement can be demonstrated upon 
the subject by placing one linger upon the pubes and the other on 
the tip of the coccyx, and observing the extent to which the pelvic 
floor projects below these two 
points. Again, by placing the pa- 
tient upon the side and flexing the 
thighs at right angles with the 
trunk, the downward displacement 
becomes apparent. In the most 
pronounced cases the parts project 
downward almost on a line with 
the nates. The physical signs of 
this condition will be referred to 
again in connection with atrophy 
of the muscles, and the differential 
points will be noted. 

Atrophy, and the consequent 
paralysis from injuries during par- 
turition and other causes, occurs 
only in cases of long standing, and 
is, in fact, a secondary state re- 
sulting from laceration of the mus- 
cles or overdistention. It may 
follow any of the injuries already 
mentioned that have been long 
neglected, or in which unsuccessful 
efforts have been made to over- 
come the original injury. The muscles, having been torn or sepa- 
rated from their ligamentous attachments during parturition, become 
functionally inactive, and remain so until they undergo fatty degen- 
eration and are finally lost. These are usually neglected cases, 
but a like condition is seen when a surgical effort at restoration 
has been made which has resulted in union of the skin and mucous 
membrane without restoring the muscles. The same thing is pro- 
duced in another way. The pelvic floor sustains an injury, slight 




Fig. 66 



of the pelvic floor. 



The 
sweep from a to b denotes the sagging 
portion of the pelvic floor. The bulging 
posterior vaginal wall (rectocele) shows 
white between the labia. 



124 DISEASES OF WOMEN. 

in itself, which is permitted to remain until prolapsus of the pel- 
vic organs produces overdistention of the muscles, and maintains 
it so long that atrophy of the muscles takes place and permanent 
loss of the function of the pelvic floor follows. Other and rarer 
cases are seen in which atrophy of the muscles occurs as the result 
of long-continued overdistention. This I have seen in cases of 
paralysis caused by hypertrophic elongation of the cervix uteri 
and small fibroids in the uterus. In these cases there was no evi- 
dence that the floor had sustained any injury other than that pro- 
duced by the prolapsus. I am also personally convinced that pro- 
lapsus of the pelvic organs may be due to injuries of the uterine 
ligaments and upper pelvic fascia while the pelvic floor sustained no 
injury whatever until the prolapsed organ caused its overdistention. 
Again, habitual constipation will cause paralysis of the muscular 
tissues of the rectum, and also (to some extent, if not wholly) of the 
levator ani, and, if this continues long enough, atrophy and perma- 
nent paralysis will follow. If to this constipation prolapsus of the 
pelvic organs is added, and they both continue for a long time, per- 
manent insufficiency of the pelvic floor will occur from muscular 
atrophy. Finally, I presume (though I can not prove) that atrophy 
of the muscles occm^s in very old women from no other cause than 
senile malnutrition. In this state of the parts other anatomical le- 
sions occur in nearly all cases. The fascia and elastic tissue are 
wanting, and the blood-vessels — notably the veins — become over- 
distended, giving a well-marked passive hyperemia. The vast differ- 
ence in the vascularity noticed in operating in different cases is 
accounted for in this way. 

The extent of prolapsus which occurs in this fonn of muscular 
insufficiency differs. In the most marked case that I have seen it 
was so great that the anus was nearly on a line with the nates while 
the patient was in Sims's position. The physical appearance of this 
affection has been already illustrated in connection with recent lacer- 
ations — the fourth injury described (see Fig. 66). The informa- 
tion obtained by inspection is usually sufficient for a diagnosis, but 
still further evidence can be obtained by the touch ; this shows the 
lax, non-resistant state of the muscles, which, as already stated, can 
not be excited to contraction by irritation or the electric current. 

In the diagnosis of all these injuries, the all-important question 
is to determine whether the paralysis is due to overdistention of the 
muscles and is temporary only, or due to atrophy, and hence perma- 
nent. This can not always be settled at once and positively. If the 
tissues of the pelvic floor appear to the touch to be lacking muscular 



INJURIES TO THE PELVIC FLOOR. 125 

fiber, and no muscular contraction can be induced by stimulation, it 
is presumptive evidence of muscular atrophy ; and yet it may be only 
a temporary loss of muscular power. It is necessary, then, to sup- 
port the pelvic floor and let the patient rest in the recumbent posi- 
tion to remove all downward pressure from the parts, and, by the 
use of astringents and electricity, endeavor to restore the muscular 
function sufficiently to prove that there is still muscular tissue pres- 
ent. If by such means the muscular function is even partially re- 
stored, the diagnosis is completed, and the indications for further 
treatment are established. It is then and only then that surgical 
treatment may be employed with the hope of obtaining complete 
recovery. Should all well-directed efforts fail to give evidence that 
the muscles still retain their true anatomical characteristics, it is use- 
less to hope for success in operating. 

Symj)tomatology. — The symptoms which are developed by injuries 
to the pelvic floor are not sufficiently diagnostic, or else they have not 
yet been sufficiently studied, to make them of decided value to the 
diagnostician. Patients express a feeling of want of support of the 
pelvic organs, or, as they express it, a dragging-down feeling, and 
some derangement of the functions of the rectum and bladder, but, 
as these symptoms occur in all the forms of injury named, and as 
they also in like manner occur in displacement of the pelvic organs, 
but little reliance can be placed upon them. When the function of 
the levator-ani muscle is lost from injury or atrophy, there is usually 
much difficulty in evacuating the rectum. This is, of course, most 
marked when the patient is constipated, but it is noticed also when 
the bowels are free, thoijgh to a less extent. "When there has been 
a laceration in the median line the scar tissue is often tender to the 
touch, and occasionally causes some general nervous disturbance. 
The sensitiveness of this scar tissue is sometimes so great as to pro- 
duce reflex muscular contraction when touched while the patient is 
angesthetized. The admission and expulsion of air from the vagina 
(flatus vaginalis) is said to occur frequently in these injuries, and it 
is no doubt one of the most reliable symptoms of injuries of the 
pelvic floor, as it rarely occurs in any other condition. 

The last of the pathological states of this structure to be described 
is muscular rigidity produced by a previous inflammation, the prod- 
ucts of which have impaired the muscular tissue. 

This affection has been classed by authors under the head of rigid 
perinseum, vaginismus, and spasmodic muscular contraction, but it 
belongs to a different pathological order of things. There are cases 
of rigidity or spasmodic contraction of the muscles due, perhaps, to 



126 DISEASES OF WOMEN. 

lijpersestliesia, but the condition under consideration is simply a 
rigid state of tlie muscles caused by the products of a former inflam- 
mation which have impaired the elasticity and motion of the muscles. 
The cases of that kind that I have seen have given a history of pel- 
vic inflammation — in two following scarlatina, in one from an injury 
sustained by falling upon the rail of a fence, and in another from a 
perirectal abscess. 'No difficulty was experienced in either case until 
after marriage, when it was found that coition was impossible. An ex- 
amination showed that the vagina was rigidly closed and the muscles 
of the pelvic floor could not be distended. All efforts to move them 
caused severe pain. In short, there was muscular anchylosis. The 
treatment for this affection commended in the books is to incise the 
pelvic floor from the vaginal orifice down to the sphincter-ani muscle, 
an operation entirely uncalled for and unsatisfactory in its results, as 
will be seen when we discuss the treatment. 

Causation. — The causes of these injuries are traumatic (exceptuig 
the last one described), that is, overdistention or stretching of the 
parts during partarition. The exceptions to this have already been 
mentioned, viz., long-continued overdistention from prolapsus of the 
pelvic organs, extreme constipation, and malnutrition in old age. 

There are, no doubt, certain states which predispose to these in- 
juries. Phlegmatic women who have failed to take exercise sufficient 
to develop these muscles are liable to lacerations during parturition. 
In such cases the muscles of the pelvic floor are poor in quality, and 
rupture easily under extreme pressure. The very opposite of this ap- 
parently predisposes to the same accidents. In vigorous muscular 
women the pelvic floor is often unyielding because of the great 
strength of its muscles. They resist the pressure of the child as it is 
forced against the pelvic floor by a powerful uterus, and, seemingly, 
rather than relax and stretch, their union at the median line gives 
way ; it is in such cases that complete laceration in the first degree 
is most likely to occur. Again, in those in whom the pelvis is shal- 
low and wide in the straits, the child passes easily through the pelvic 
canal, when rather sudden, unrestrained pressure comes upon the 
parts and they are very liable to give way. In others still, either from 
habits of life or the position of the uterus in relation to the pelvis, 
the return circulation is retarded, the vessels become overdistended, 
and a deranged nutrition, with' softening of the tissues of the pelvic 
floor, renders them easily torn. 

The immediate cause of lacerations — whether subcutaneous or 
complete — is distention during delivery. The tissues in the median 
line give way in the great majority of cases because the greatest 



INJURIES TO THE PELVIC FLOOR. 127 

pressure is brought to bear at that point. That the laceration ex- 
tends to, but not through, the sphincter-ani muscle, as a rule, is no 
doubt due to the strength of this muscle. In fact, it is a matter of 
surprise that the sphincter is ever lacerated when its position is con- 
sidered in relation to the force brought to bear upon it. The only 
rational explanation of the laceration which I have been able to ob- 
tain from a careful clinical study of the matter is as follows : The 
transversus-perinsei, levator-ani, and bulbo-cavernosus muscles are 
so strongly attached to the sphincter-ani muscles that, during de- 
livery, wdien the head distends the pelvic floor they hold the sphinc- 
ter ani upward and forward. If the size of the head is out of pro- 
portion to the distensibility of the pelvic floor, one of two injuries 
must occur : either the muscles attached to the sphincter must give 
way and permit the sphincter to recede downward and escape injury, 
or else the sphincter must be torn through. This effect of the other 
muscles upon the sphincter ani during delivery of the child's head 
can be seen by the way in which the sphincter ani is drawn upward 
until the anus is distended an inch or two. While the fetal head was 
unusually distending the^pelvic floor, and while the hand was placed 
upon the parts to " support the perinseum,- ' I have felt, or fancied 
that I could feel, the muscles attached to the sphincter ani give way 
and permit the rectum to recede and escape injury. 

Regarding the causes of injuries to the levator-ani muscle, one 
has but to recall the phenomena of labor as related to it to under- 
stand how^ it may be freely lacerated in ordinary labor. It cer- 
tainly is as freely exposed to injury as the other muscles which 
w^e know are frequently lacerated subcutaneously. In delivery wdth 
forceps, the levator-ani muscle is frequently injured, I believe. 
While the child's head is in the grasp of the forceps and during 
traction, I have noticed, by passing the finger into the rectum, that 
the levator ani w^as drawn so tightly over the edges of the blades of 
the forceps that it appeared as if it must be torn, and I feel sure 
that it often is. I am the more fully convinced of the truth of this 
by having carefully watched patients that I had delivered with for- 
ceps, and have found in some of them evidence of injury of the 
levator ani above its lower attachment. That evidence w^as obtained 
by finding, on subsequent vaginal examination, that the resistance 
of the levator muscle usually found was wanting, and also that there 
was prolapsus of the pelvic floor, and loss of contractility upon irri- 
tating the parts. 

Treatment. — The object in treating these injuries should be to 
restore the lacerated muscles by securing union of theii* severed 



128 DISEASES OF WOMEX. 

fibers. In the ordinary or most commonly recognized injury, lacera- 
tion in the median line down to. but not through, the sphincter, the 
immediate treatment usually employed is to close the womid with 
sutures at once, or to cleanse the wound from blood-clots and coapt 
the parts, carefully bind the patient's limbs together, and trust that 
imion may follow. The treatment by the immediate use of the 
suture will be made plain by the following : 

Primary Ojperation. — The wound, if seen when it occurs, is tri- 
angular, the base running parallel to the rectum and the apex being 
at the posterior part of the vulva. The sides of the wound come to- 
gether quite easily, and only require well-adjusted sutures to keep 
them in position. Much care is necessary in using the sutures. If 
they are imperfectly introduced they do harm by preventing the union 
which often takes place without surgical aid. If one is not accus- 
tomed to this simple operation of closing the wound with sutures, it 
would be infinitely better for the patient to trust to nature than to 
have the surgeon employ sutures in a bungling way. The sutures 
should be introduced as foUows: The needle, held in the groove at 
right angles to the forceps, should be entered in the skin exactly at 
the edge of the wound, and as far down as the deepest part ; it is then 
carried into the tissues and made to describe the arc of a circle and 
emerge at the margin of the mucous membrane of the vagina. The 
needle is again introduced on the opposite side and carried through as 
before, and brought out at the point in the skin opposite where it was 
first introduced. If this is properly done, the position of the suture in 
the tissue will be as represented in Fig. 67. The center lines repre- 
sent the sides of the wound and the dotted 
Tnenil)v3,-ne. ^ii^e shows the suture, which describes a 
circle, the point at which the suture is 
I tied and the opposite point of its cir- 

/ ^' cumf erence being at the upper and lower 

angles of the wound. There are three 
advantages in using the suture in this 
wav : First, the ends of the suture com- 

67.-Diagram of the sweep of -^ : ^^^ ^^ ^j,^ ^^ ^f ^^^ WOUnd hold 

the suture. ^ o 

the parts exactly together without the 
aid of superficial sutures ; second, the curve which the suture takes 
deep under the tissues brings the central portions of the wound to- 
gether, whereas, if the suture is passed straight through the tissues, 
the edges of the wound would curve inward, while the central parts 
would not meet. Fig. 68 shows the parts adjusted by a proper su- 
ture, while Fig. 69 shows the effect of the imperfect one. Again, 




INJURIES TO THE PELVIC FLOOR. 129 

the suture running deep into the tissues gives additional surety of 
catching the ends of the muscles so as to reunite them, which is the 
cliief object of the operation. In the pri- 
mary operation — i. e., the introduction of su- / 
tures immediately after the injury occurs — ; 
Peaslee's needle is easier to use than the or- '\ 
dinary perineal needle. Fig. 70 shows the *=*'=^ 
instrument. This needle, with a handle, and '' ' 
an eye near the point, is armed with a thread fi^s 68, 69.— Sutures proper- 

•^ 1111 . 1 1 V ^J^d improperly introduced. 

and passed through the tissues as already 

described, and the end of the suture is passed under the thread in 
the needle ; this is then withdrawn and brings one end of the suture 
into the tissues. The operation is repeated on the other side, which 




Fig. 70. — Peaslee's needle. 

completes the introduction of the suture. The only advantage of 
this needle is that it is easier to manage than the ordinary one 
It can only be used, however, in the primary operation. The silk 
suture properly prepared is by far the best for the immediate opera- 
tion. Silver wire, which at one time was the only suture which 
could be rehed upon, has been superseded by others that are vastly 
superior for this purpose. It is impossible to keep the parts clean 
after confinement without causing pain while the ends of silver-wire 
sutures are projecting from the parts. The silk sutures save the 
patient much discomfort, and are not in the way of the means neces- 
sary to be used to keep the parts clean. 

This constitutes the whole primary treatment of injuries of the 
pelvic floor, as given in our text-books — a kind of management gen- 
erally sufficient in central lacerations, but that can have little influ- 
ence in restoring the other forms of injury. To secure the reunion 
of the muscles that have been lacerated subcutaneously, especiallv 
the levator ani, the parts should be well supported and kept at rest. 
If the pelvic floor is permitted to remain in its relaxed and displaced 
position there is but little chance of the lacerated muscles uniting, 
nor, in case they are simply overtaxed by distention, will they regain 
their tonicity promptly if left unaided by support. Especially is 
restoration likely to be prevented if the patient is permitted to as- 
sume the erect position too soon, and if, to increase the injurious 
effects of this unwise liberty, the uterus is crowded down into the 
10 



130 DISEASES OF WOMEN". 

pelvis by a compress and tight bandage applied around the body. 
In all cases of injury in which concealed laceration of the muscles is 
suspected, the pelvic floor should be well supported with a compress 
and bandage fastened to the abdominal binder. By these means the 
severed ends of the muscular fibers are brought nearer together, so 
that they have a better chance to unite. An objection would natu- 
rally be raised to this treatment on the ground that it would obstruct 
the free flow of the lochia. This can be overcome by making the 
compress of absorbent cotton, antiseptic gauze, or marine lint, and 
draining the vagina with a drainage-tube or a strip of gauze or lint. 
I believe that in this way the vagina can be drained and kept as 
clean as it can be by occasional douching. In fact, I am inclined to 
think that the very frequent use of vaginal injections so generally 
employed in this age of antiseptic obstetrical practice often tends to 
retard the restoration of injuries of the pelvic floor. It is well, also, 
to let the patient rest upon either side after the first twelve or 
twenty-four hours. This position takes off all pressure from above, 
and favors the upward inchnation of the pelvic floor. Great care 
should be taken to avoid distention of the bladder and rectum. Con- 
stipation after confinement is almost sure to prevent or, at least, 
retard recovery. By attending to these simple means much can be 
done toward preventing that incurable condition, permanent paraly- 
sis from atrophy. 

After convalescence from confinement, in case it is found that, 
although there is no complete loss of muscular action in any part of 
the pelvic floor, there is a muscular weakness shown by the impaired 
power of resistance to pressure, the supporting treatment, with judi- 
cious rest and exercise w^ell regulated, should be kept up until 
strength is restored. 

The restoration of the function of the muscles, as already stated 
in speaking of general treatment, is the great object of all surgical 
operations for the relief of these injuries of the pelvic floor. It 
matters not how much tissue may be gathered together and united 
in the region of the perineal body, it will have no functional action 
if destitute of muscular tissue. The success of all surgical proced- 
ures depends upon the restoration of the muscles, elastic tissue, and 
fascia, and not the mere uniting of the tegumentary and areolar 
tissue. 

In this plastic operation, known as perineorrhaphy, or restoration 
of the perinseum, much surgical skill is necessary in order to succeed. 
This is true of all operative surgery, and yet special care is necessary 
in this operation, because union by first intention must be secured 



INJURIES TO THE PELVIC FLOOR. 131 

or else the operation will fail. In many operations in surgery, if 
the wound does not heal by first intention, union may be secured by 
granulation and a perfect result obtained ; but in the operation 
under consideration, if the whole or any part fails to unite promptly, 
partial or complete failure is the result.. This calls for the employ- 
ment of all known surgical means most favorable to prompt healing. 
On this account, then, some general considerations regarding plastic 
operations in gynecology will be in place before describing the 
methods of operating. What will follow on this subject will apply 
equally to all operations about the pelvic floor and pelvic organs, 
especially lacerations of the cervix uteri. 

The following may be given as the conditions necessary for the 
healing of the wounds in question : 

1. A condition of the wound and of the general system favorable 
to the repair of injuries. 

2. Perfect coaptation and retention of the parts to be united, and 
protection of the parts from extrinsic and offending agents during 
and after coaptation. 

If these conditions are all secured, success must of necessity fol- 
low. The management of wounds is not a matter of blind chance. 
The process of repair in living tissues is governed by definite laws 
which are always the same under identical circumstances. To ob- 
tain the conditions necessary to the fulfillment of these laws is often 
difficult and sometimes impossible; still, the nearer we come to all 
the requirements the more surely will the desired ends be accom- 
plished. 

The first of these conditions, viz., good general health, may be 
found wanting in many ways and degrees which are too familiar to 
require notice, but there are some of these which may be mentioned 
because they are very often overlooked — preoccupation of the sys- 
tem by some highly taxing function, like lactation, for example, and 
certain deranged states of the nervous system. These certainly have 
an important bearing upon the healing of wounds, although little if 
anything is said in our works on surgery regarding them. In fact, 
there is good reason for believing that enfeebled states of the nerv- 
ous system have much to do with retarding the healing of wounds, 
even when the general nutrition appears to be normal. We fre- 
quently hear surgeons say that. patients recover from injuries much 
more promptly when they have courage and hope without fear ; but 
exhausted and irritable states of the nervous system retard the pro- 
cess of repair, although the patient may be indifferent or perfectly 
satisfied in regard to recovery. 



132 DISEASES OF WOMEX. 

Regarding the unfavorable conditions of the tissues generally 
met with, the following are the most important : 

Contusions. — Contusions accompanying wounds caused bv par- 
turition. Lacerated wounds of the pelvic organs often heal promptly 
if well coaptated immediately after they occur, bnt no such nnion 
should b3 expected in case the tissues are greatly contused. While 
this is true of the immediate treatment of wounds sustained during 
labor, it is pretty definitely settled that operation wounds made dur- 
ing the process of involution — that is, within four or six weeks after 
confinement — often fail to unite. From this we learn that while 
tissues are undergoing involution they are not in the best condition 
to heal ; and also that, when involution is delayed beyond the usual 
time, treatment should be employed to complete the process before 
undertaking plastic operations. 

Scrupulous care is also required in preparing the tissues by mak- 
ing clean, accurate incisions which will give smooth surfaces to the 
parts to be united. Old scar tissue should also be removed from all 
wounds where union by first intention is desii-ed. These are rules 
in surgery which are well known, but they are sometimes overlooked 
in practice. 

Hoemorrhage. — Haemorrhage in these operations is often a source 
of difficulty and delay to the operator, but, worse than that, it is 
sometimes the cause of failure. In the vast majority of surgical 
operations all that is required of the surgeon is to arrest the haemor- 
rhage, by any of the ordinary means, in order to secure a good re- 
sult ; but in the operations in question, if some kinds of styptics 
are used, they prevent union. Cases differ so very much in regard 
to haemorrhage that I have given much thought to the predisposing 
causes of this bleeding tendency, so marked in some patients. The 
haemorrhagic diathesis in its most typical form is generally found 
in men, but a less marked haemorrhagic tendency is common to 
many women, and these are very unpleasant subjects to operate 
upon. During the past few years it has been my misfortune to 
meet with quite a number of cases in which the bleeding tendency 
was noticeable. The cause of this in most of them, I think, was im- 
paired general health, due to exhausting conditions of life rather 
than to any congenital imperfection of the blood itself. Another 
very important element I have found to be mechanical interruption 
of the circulation, the pelvic organs becoming congested from re- 
tardation of the portal circulation, induced by hepatic disorders, 
sedentary habits, tight lacing, and so forth. The products of former 
pelvic inflammations, such as pelvic cellulitis, also tend to maintain 



INJURIES TO THE PELVIC FLOOR. 133 

a hjpergemic state of the pelvic organs ; this we often find long after 
all evidence of active inflammation has subsided. The condition at 
the time also is often favorable for bleeding ; the well-defined vas- 
cularity which exists in conditions such as imperfect involution in- 
sures hgemorrhage in all operations undertaken during such unfavor- 
able states. The possible haemorrhage from such causes can be 
avoided bj the proper selection and preparation of cases before oper- 
ating. 

The rule which should be followed in this matter is to secure the 
best possible state of the general health of the patient, and to reduce 
all hypersemic states of the pelvic organs as far as possible. This is 
generally possible to a great extent, because the object of plastic 
operations is to restore the organs to their original form and struct- 
ure, differing in this regard from many other operations in surgery 
which have for their object the removal of diseased parts. 

In carrying oat this plan of treatment, however, there is one 
difficulty encountered in practice ; when patients are ill and suffer- 
ing they will gladly accept any operation which promises them relief, 
but, when they are free from pain and have gained in health, they 
hesitate about undergoing any surgical treatment which is designed 
to keep them from suffering in the future. This, however, does not 
prevent the surgeon from advising that which is best. There are 
patients — fortunately very few — who have the hsemorrhagic diathesis 
sufficiently marked to debar them from operations, and it is doubtful 
if any preparatory treatment will change this constitutional pecul- 
iarity.. Such subjects should be let alone ; to operate in these cases 
is dangerous, and almost always ends in failure. I have had three 
such cases in the past five years ; two of them were operated upon 
before discovering their peculiarity, the result being depletion of 
the patients without any benefit from the operation, and the devel- 
opment of extreme caution on the paii; of the operator in selecting 
eases in future. The third case was diagnosticated earlier, and I 
declined to operate. 

The management of bleeding vessels in these operation wounds 
is of great importance. All haemorrhage should be arrested before 
bringing the parts together, because a slight oozing, which would do 
no harm in a wound to be treated by open dressing, may prevent 
union in wounds in which drainage should not be employed, or, at 
least, should not necessarily be required. This often requires an 
amount of time which the surgeon reluctantly bestows, but success 
in treating this class of wounds depends largely upon attention to 
this matter. Still more, the means used to arrest haemorrhage should 



134: DISEASES OF WOMEK 

be such as will not interfere with the process of healing. Hitherto 
the means employed have been ligation or torsion of the large vessels, 
and for minor bleeding the use of ice or cold water. More recent 
experience has pointed out objections to these means. Chilling the 
tissues by cold is injurious, it is said, and no doubt the statement is 
true. It has, fortunately, been found that hot water is more efficient 
in controlling hsemorrhage, and its effects upon the tissues are not 
unfavorable — hence its use as a styptic in these operation wounds is 
strongly commended. Torsion is objectionable, because it is less 
certain to control bleeding than the hgature, and quite as liable to 
give rise to suppuration. In view of this fact, it may be said without 
doubt that the antiseptic ligature is the best means of controlling the 
vessels in these wounds. Regarding the material to be used as a 
ligature, it may be said that that which can be inclosed in the wound 
without giving subsequent trouble is the thing required. The prop- 
erly-prepared catgut ligature fulfills the indications. Some recent 
experience indicates that the Japanese ligature, made of whale-sinew, 
is the best, owing to its being absorbed with great facility. Occa- 
sionally, in deep lacerations, a small artery on each side may require 
to be ligated ; the chief arterial bleeding, however, comes from the 
upper portion, the small vessels coming apparently from above down- 
ward in the areolar tissue, between the rectum and vagina. These 
sometimes bleed quite freely, and they are not controlled by tighten- 
ing the sutures, which arrest the haemorrhage at points lower down. 
Such vessels I control by passing a needle through the vaginal mu- 
cous membrane above the denuded surfaces, and thus carry a ligature 
under the bleeding vessels, tying it over the free surface, checking 
the bleeding on the principle of acupressure. The sutures can be 
left in position until the perinseum has completely healed ; they can 
then be removed with the aid of the speculum. Occasionally it be- 
comes necessary to ligate some of these vessels which bleed persist- 
ently and can not be controlled in the way I have previously de- 
scribed ; it is then well to hgate them with a fine catgut ligature, the 
ends being cut off short and inclosed in the wound. 

In spite, however, of aU precautions, secondary haemorrhage will 
occasionally occur after this operation. I have met with four such 
cases in my practice ; in one of them it occurred on the seventh 
day after the operation. In aU of them the bleeding took place from 
the upper or vaginal portion of the wound, the blood flowing into 
and widely distending the vagina before appearing externally. 

In my first case I was obliged to remove the sutures, empty the 
vagina of blood-clots, and ligate the bleeding vessels. This resulted 



li^JUPJES TO THE PELVIC FLOOE. 135 

m spoiling my operation, for, although I reintroduced the sutures, 
union did not take place. This haemorrhage occurred on the sec- 
ond day. 

In my three subsequent cases I secured much better results. In- 
troducing a Sims's speculum on the anterior side of the vagina, I 
removed the clots and blood by sponging, and then, throwing light 
into the vagina by means of a concave reflector, I was able to see 
that the blood welled up from the upper portion of the wound. In 
place of pulling the edges of the wound apart and searching for the 
bleeding vessels, I passed a curved needle and hgature down and 
around the place where the bleeding came from, and was able, by 
tightening my ligature moderately, to control the bleeding entirely. 
These cases subsequently did well, and the result of the operation 
was good. 

Sutures. — The coaptation of the tissues by means of sutures re- 
quires more than a passing notice. 

The success which J. Marion-Sims obtained with the silver- wire 
suture led at once to its general use in gynecological operations. 
There is, however, good reason for believing that the results obtained 
by that great surgeon depended as much upon his skill in using sut- 
ures as upon the material which he used. 

To-day we know that it matters little whether silver-wire or pre- 
pared silk sutures are used, provided they are properly introduced. 
The silk selected should be braided, and not the twisted variety, for 
the reason that the braided silk retains wax much better, and does 
not unravel on being handled. The wax in the twisted silk breaks 
and separates from the silk, and the silk thereby becomes porous 
and will absorb blood-serum which readily decomposes. The reason 
why surgeons formerly failed in the operation for vesico- vaginal 
fistula, when they used silk, was because the organic matter, ab- 
sorbed by the unprepared silk, decomposed and caused septic inflam- 
mation. The braided silk, properly saturated with wax, overcomes 
this completely. The parts to be united should be brought together 
and held there without any sti-aining upon the sutures. It is equally 
important to introduce the sutures so that they will prevent the in- 
curving of the undenuded edges of the parts to be united, and, 
finally, a sufficient number of sutures should be employed to secure 
uniform retaining pressure at all parts of the wound. 

These are facts which every one is supposed to know before en- 
gaging in surgery, but in practice a large number of failures are seen 
because of neglect in regard to them. 

The management of these wounds during the healing process 



136 DISEASES OF WOMEN. 

differs somewhat from tlie modern treatment of wounds in gen- 
eral. 

Dressings. — The antiseptic dressings which surgeons use in some 
form or other are difficult of application in the operations for restor- 
ing the cervix uteri and perinseum. So fuUj is this the case that 
some of our highest authorities on gynecology make no pretensions 
to using antiseptic treatment in such wounds, unless frequent bath- 
ing of the parts with water and carbohc acid may be called such. 
]!S"o doubt some of our best operators get good results with this kind 
of after-treatment, but it is more than probable that still better re- 
sults can be obtained by treatment more in accordance with the rules 
of antiseptic surgery. Viewed in the light of modern investigation, 
it appears that the frequent douching of wounds with carbolized 
water is a practice at least ten years behind the surgery of to-day. 

In treating wounds of the perinseiim there are many perplexing 
difficulties in the way of obtaining a proper antiseptic dressing. 
Here, also, the vaginal douche has been freely used, for the purpose, 
it is said, of removing vaginal secretions which might irritate the 
wound and prevent its healing. Such treatment is generally un- 
necessary, if not injurious. In all operations for repairing old injuries 
of the perinseum it is better to first cure all uterine and vaginal dis- 
eases which give rise to abnormal discharges. That is the only sure 
way of protecting the operation wound from that source of disturb- 
ance. This, of course, can not be accomplished in the treatment of 
lacerations immediately after confinement. Then it becomes a very 
important question how to protect the perineal wound from the 
lochia. Yarious means have been suggested for this purpose, such 
as coating the vaginal surface of the wound with collodion, placing 
carbolized lint or borated cotton upon the inner portion of the wound, 
and, the most common of all, the frequent use of vaginal injections. 
It is hardly possible to say, at the present time, which is best. The 
collodion has not been tried often enough to speak positively regard- 
ing it. In using the lint or cotton there is danger of separating the 
edges of the wound, the very thing of all others to be avoided. 
Perhaps the best treatment, after carefully cleansing the parts and 
bringing them accurately together, is to let the wound alone for about 
two days, trusting that during this time it may become sufficiently 
protected, by a coating of fresh IjTuph, to resist the subsequent dis- 
charges. After the lochia begin to decompose, the frequent use of 
the vagina] douche is advisable, and should be continued until the 
union is completed. 

In the secondary operation for restoring the perineum, the vag- 



INJURIES TO THE PELVIC FLOOR. 13T 

inal portion of the wound may generally be left alone. It is pro- 
tected from the air by the anterior vaginal wall, which makes a suit- 
able dressing provided the uterus and vagina are in a normal condition, 
as they should be, before the operation is done. If suppuration takes 
place and pus is discharged into the vagina, it should be disposed of 
by injections. The outer portion of the wound may also be left 
without dressing, but it is better to apply lint or cotton upon each 
side of the sutures ; if silver wire is used, or if silk is employed, the 
lint can be placed over the wound and retained in place by keeping 
the limbs together. The advantage of this kind of dressing is that 
it absorbs any discharge that there may be. 

Perhaps the most important point of all in the management of 
such cases is to keep from dropping urine upon the w^ound. The most 
scrupulous care should be taken to close the end of the catheter in 
withdrawing it. If this is neglected, a few drops of urine will escape 
from the eye of the instrument, and, falling upon the wound, will 
cause trouble. The -nurse should be carefully instructed to use the 
catheter in this way, and, to make doubly sure of cleanliness, a little 
absorbent cotton should be placed between the meatus urinarius and 
the wound every time the instrument is used. 

Notwithstanding all this care, suppuration will sometimes occur, 
and then the question arises how to manage this complication. If 
the suppuration is limited to the track of one suture, that one may 
be removed and the remaining ones trusted to keep the parts to- 
gether. It sometimes happens that a cellulitis which begins in the 
region of the sutures extends outward and ends in suppuration. 
This should be treated by a free incision and drainage, which may 
save the operation. On the other hand, if suppuration takes place 
between tlie surfaces to be imited, there is very little hope of obtain- 
ing union at all by any kind of treatment. A partial or even com- 
plete success may be obtained in such cases if the suppurative process 
is detected early, and drainage from the lower edge of the wound is 
established. This can be effected by loosening one or more of the 
sutures, and then introducing carbolized silk thread or catgut to 
secure the free escape of the inflammatory products. 



DESCRIPTION OF THE OPERATION FOR RUPTURE IN THE 

FIRST DEGREE. 

Yelpeau, of Paris, was the surgeon who first operated for the 
restoration of the perin?eum. 

The first part of the operation consists in denudino- the surfaces 

10* 



138 



DISEASES OF WOMEIST. 



to be united. The extent to whicli this should be carried depends 
upon the character of the injury. If there is no prolapsus of the 
pelvic floor or of the posterior vaginal wall (see Fig. 66), it will suffice 
to denude the surfaces as far as the original laceration extended and 
no farther. This can be done by tracing the outline of the scar tis- 
sue formed by the healing after the laceration. This scar tissue con- 
tracts and brings the normal tissues toward each other so that the 
portion to be exsected, as indicated by the rule given here, appears 
to be very small and insufficient ; but, when the scar tissue is re- 
moved, the skin and mucous membrane retract and make the denuded 
surface large enough — much larger, in fact, than the piece of tissue 
taken away. If more tissue is removed in such cases and good union 
is obtained, the introitus vaginae is made too small. 

When the sides of the laceration are drawn outward and the pel- 
vic floor is j)rolapsed, and the distance from the meatus urinarius to 
the anterior portion of the sphincter ani is increased to an abnormal 
degree (see Fig. 66), the denudation should be made high enough on 
either side to make sure, if possible, to unite the loose ends of the 
bulbo-cavernosus muscle. To do this the original scar tissue should 
not be taken as a guide in vivifying the parts. On the contrary, the 
vivifying should be carried upward on either side to within an inch 
or less of the lower side of the vestibule. In tbis condition there is 
usually prolapsus of the posterior vaginal wall, and when such is 
the case, the denudation should be carried upward nearly to the high- 
est point on the prolapsed portion of the vaginal wall. (See Fig. 67.) 

The instruments for denuding the parts are a number of sponges 
fixed in holders, a tissue forceps (see Fig. 71), and Emmet's curved 




Fig. '71 



-Tissue forceps. 



scissors, four in number, two with lesser curves and two with greater. 
(See Figs. 72 and 73.) These instruments can not be described; 
they must be seen to be understood. 




INJURIES TO THE PELVIC FLOOR. 



139 



The method of operating is as follows : The patient is placed 
upon the operating-table in the lithotomy position ; an assistant on 




Fig. 73. — Emmet's scissors. 



each side holds the limb of that side in the flexed position with one 
hand, while with the other he separates the labia to f uHj expose the 
parts ; the operator, seat- 
ed in front of the patient, 
seizes the tissues with the 
forceps on the left side as 
high lip as the denudation 
should extend, and wdth 
the scissors removes a strip 
at the junction of the skin 
and mucous membrane 
across to a corresponding 
point on the right. The 
end of the strip should 
be left attached, the other 
scissors taken, and the 
strip continued back to 
the left again. In this 
way the continuous strip 
may be taken out from 
one side to the other and 
back again until the whole 
surface is denuded. The 
three figures will give a 
better idea of the mode 
of procedure than this de- 
scription. 

In case there is pro- 
lapsus of the vagina — and it is therefore necessary to carry the 
denudation high up on the vaginal wall — the scissors with the great- 
est curve should be used at tliat part of the procedure. 

When the whole surface has been denuded in the uiaiinor de- 




FiG. 74. — First step ; denudatioia begun. 



140 



DISEASES OF WOMEN. 



scribed, it is necessary to make sure tliat the edges of the wound 
are straight and alike on both sides, and that the surface is smooth. 

This can be accomphshed 
by causing the assistants 
to put the parts upon 
the stretch, when careful 
sponging will show any 
irregularity which needs 
to be trimmed off. By 
passing the finger over 
the fresh surface, any 
scar tissue that remains 
can be detected by its 
density and resistance 
compared with the soft- 
ness and elasticity of the 
normal tissue. 

At this stage of the 
operation attention should 
be given to haemorrhage. 
If there are any spurt- 
ing vessels in the wound 
they should be controlled 
by suture or ligature. 
Fortunately, when such 
vessels are encountered, 
they are generally at the 
upper margin of the 
wound, and may be controlled by passing a fine suture through the 
mucous membrane of the vagina and under the vessel and then 
tying it tight enough to stop the bleeding. This has been already 
noticed under the head of general observations. 

'Next in order comes the introduction of the sutures, and just 
here it may be stated that for all plastic operations I use silk sutures 
prepared as follows : The ordinary braided silk is immersed five or 
six hours in wax containing six per cent of carbolic acid and six per 
cent of salicylic acid. The wax is kept all the time at a tempera- 
ture high enough to liquefy it. This long immersion in the melted 
wax is necessary to thoroughly saturate the silk. When this is ac- 
complished, the silk is drawn through a carbolized sponge to remove 
any excess of the wax. It is then put on a reel which is placed in a 
close-stoppered bottle and kept until required. Xos. 5 and 7 are the 




Fig. ^5. — Second step ; continuing the strip. 



INJURIES TO THE PELVIC FLOOR. 



141 



sizes used ; No. 7 for the lower suture and 'No, 5 for the upper ones. 
The needles employed are the ordinary darning needles found in the 
dry-goods stores, vary- 
ing in length from 
two inches and a quar- 
ter to one inch and a 
half. The larger nee- 
dles are armed with 
No. 7 thread and the 
smaller with No. 5. 

To manipulate 
these needles it is 
necessary to have a 
suitable forceps, and 
for this I have devised 
the instrument repre- 
sented by Fig. Y7. It 
is a double forceps. 
The central portions 
of the two blades 
which form the han- 
dle are made of spring 
steel. The halves cross 
each other at about an 
inch from each end 
to form the jaws. At 
one end there are 
three grooves which 
receive the needle and 
hold it at an acute, 

obtuse, or right angle, whichever the operator may require. The 
other jaw, w^hich closes over the grooved one, is file-faced, which 




Fig. 



'76. — Vivifying complete ; the vaginal sutures on one 
side are inserted. 




Fig. 77. — Needle-forceps, 



keeps the needle from slipping through the grooves when pressure 
is made upon it. The jaws of the other end are copper-faced and 
are used to grasp the point of the needle in drawing it througli. 
The elastic spring of the handle portion opens the jaws at each 
end, the needle is introduced into the desired groove, the handle i?? 



142 



DISEASES OF WOMEN". 



'-fl 



Fig. 18. 



grasped, whicli closes the jaws and holds the needle perfectly immov- 
able, no matter how much pressure may be brought to bear upon it. 
When the jaws are closed there is a stop-catch that holds the two 
halves of the handle together and keeps a firm hold upon the needle. 
The needle is carried into the tissues while it is held by the grooved 
and file-faced jaw ; it is then unfastened by drawing back the catch, 
the forceps is reversed, and the point of the needle seized in the cop- 
per-faced jaws and withdrawn. The advantage of the copper-faced 
jaws is that they seize the point of the needle firmly 
enough to draw it through the tissues without injuring 
the point ; a valuable feature in such an instrument. 

The sutures are introduced as follows : The needle 
— placed in the forceps at right angles to it — should be 
entered in the skin exactly at the edge of the wound 
at the lowest external angle of the denuded tissue. It 
is then passed outward deep into the tissues, then curved 
round iu the tissues in front of the rectum and deep into the tissue 
of the other side, and 
made to emerge at a 
point corresponding 
to the one where it 
was entered. If this 
is properly done, no 
part of the suture will 
be seen. Its position 
in the tissues will be 
as represented in Fig. 
78. The dotted line 
represents the suture 
which describes a cir- 
cle, and the straight 
line shows the sides 
of the wound as they 
are brought together 
where the suture is 
tied. Sometimes when 
the tissues are rigid it 
is difficult to introduce 
the first suture with 
one sweep of the nee- 
dle. It is then better 
to pass the needle ir 







Fig. 79. — The stitches in place ; the vaginal sutures tied. 



INJURIES TO THE PELVIC FLOOR. 



143 




througli half of the vivilied portion, to draw it out and re-insert it 
at the same point, and to carry it around through the other side. If 
there is sufficient tissue between the base of the vivified part and 
the rectum, the second and third sutures may be introduced like the 
first — each one being passed at a higher point. The fourth suture 
(see Fig. Y9) is introduced through the side. It is then carried 
through about three eighths of an inch of the vivified portion of the 
vaginal wall, and then passed through the other side. The last suture 
is passed through 
both sides, as 
shown in Fig. 81, 
the position of 
the sutures being 
viewed in profile. 

When more 
than five sutures 
are used, the fifth 
is passed like the 
fourth, only a 
little above it. 
Most operators in- 
troduce the in- 
dex-finger into the rectum, to guide the introduction and passing of 
the needle. This should not be done under any circumstances, be- 
cause, by so doing, the rectal wall is crowded forward, and is sure 
to be included in the suture, and, besides, it is a violation of the 
rules of antiseptic surgery to operate with dirty fingers. 

In many cases there is very little tissue left in the perineal body 
after the vivifying is completed. The muscular coat of the vaginal 
wall having become atrophied, or torn from its attachments to the 
floor of the pelvis, there is only the mucous membrane left, and, 
when that is removed in denuding the parts, the wall of the rectum 
is all that is left above the skin and sphincter-ani muscle. When 
such is the case, the first suture only should be carried through the 
tissue, as already described ; the others should be introduced as 
shown in Fig. 79. 

The great advantage of this is, that the sides of the wound are 
brought together in front of the rectum, the place where the perineal 
body should be. Furthermore, the sutures introduced in this way 
avoid the rectal wall — a very important desideratum, as we know 
from the fact that when any of the sutures are, intentionally or by 
accident, passed into the wall of the rectum, they cause nuieli pain 



Fig. so. — Laceration with rectocele. (The 
dotted line gives the normal location 
of perineal body.) 



Fig. 81.— Perineal 
body restored. 
(Profile view.) 



144 DISEASES OF WOMEN". 

and rectal tenesmus, and greatly distress the patient, especially when 
the bowels move. When the sutures are all in place, the wound 
should be carefully cleansed of all blood- clots, and, if there is still 
some oozing of blood, traction should be made upon the sutures ; if 
that controls the bleeding, the sutures should be tied in the ordinary 
way. While they are being tied the sides of the pelvic floor should 
l)e pushed up by the assistants, to bring the wound together. 

The after-treatment and other points, such as the removal of 
the sutures, will be brought out in the history of the following 
cases : 

Case of Central Laceration extending to the Sphincter Ani ; Uncom- 
plicated. — The patient, a spare, small woman, had always been in 
good general health. She had been married nine years, and had 
one child eight years old. Her labor was easy and rapid, and her 
convalescence uninterrupted, excepting that she had a leucorrhoea 
which began after the lochia stopped, and continued until the time 
when she sought medical advice. Her menses returned ten months 
after her confinement and one month after her child was weaned. 
Six years after her confinement she overtaxed her strength, and then 
her leucorrhoea became more profuse, and she began to suffer from 
backache and slight pelvic tenesmus, especially upon standing or 
walking. She was slightly constipated, but in all other respects was 
well. She sought medical advice because of these symptoms and her 
sterility. An examination showed a laceration, but no other injury 
to the pelvic floor. The posterior and lateral parts of the floor were 
well sustained, and there was very little separation of the sides of the 
laceration. There was commencing prolapsus of the posterior vagi- 
nal wall, but so slight that it was only apparent upon separating the 
labia and causing the patient to cough or make downward pressure. 
The uterus was slightly below its normal elevation, but not changed 
in its axis. The leucorrhoea was due to a cervical catarrh, which 
promptly yielded to treatment. 

Five days after a menstrual period her bowels were freely moved 
in the morning by a dose of pulv. glycyrrhizse comp., given at bed- 
time the night before. On the following morning the bowels moved 
spontaneously, and, an hour later, an enema of borax and warm 
water was given to wash out the rectum. For breakfast she had a 
cup of coft'ee and a bowl of clear beef -soup. A large vaginal douche 
was used of borax and hot water to cleanse the parts thoroughly. At 
twelve, noon, she was anaesthetized with ether, and the operation 
was performed according to the method already described. The 
bleeding was easily controlled by the sutures. A small pledget of 



INJURIES TO THE PELVIC FLOOR. 145 

marine liut was placed over the wound and the knees bandaged to- 
gether. Soon naosea followed, but no vomiting, and late in the even- 
ing she was comfortable, having only a feeling of slight burning in 
the region of the wound. She took a small cup of tea, and slept 
several hours during the night. 

'Next day she had milk, soup, and gruel. The catheter was used 
for the first forty-eight hours, and after that, when necessary, she was 
rolled over upon her face, and, with a bed-pan placed under her, she 
urinated without further help. On the morning of the third day 
she took a Seidlitz powder, and at noon an enema of castile soap and 
water, which moved the bowels freely and easily. After this the 
bowels were moved daily with an enema and she had her usual food. 
The marine lint was kept upon the outside of the wound for five 
days, changing it daily. There was no discharge from the vagina 
or wound. There were no vaginal injections used, and the wound 
was not washed at any time. In fact, after the fifth day, she had no 
local treatment. On the eighth day the sutures were removed in 
the following way : She was placed in Sims's position on the bed ; 
the nurse separated the nates, which exposed all the sutures without 
making any traction upon the parts ; each suture was seized with a 
forceps, and, with the tenaculum blade of the scissors, one side of 
the thread was caught up and divided. Fig. 82 shows the scissors 




Fig. 82, — Scissors for removing sutures. 



used for the removal of sutures. It answers the purpose well, and 
guards against clipping off both ends and leaving the suture in the 
tissues, an accident which not unfrequently happens. This method 
of removing the sutures is very much simpler than trying to remove 
them with the patient upon the back. 

The patient was kept in bed until the twelfth day after the opera- 
tion, but during that time she was permitted to change her position 
from the back to either side without help. On the thirteenth day 
she was permitted to sit in a chair, and on the fifteenth day she was 
allowed to begin to walk. 

Two months after the operation she was examined, and the space 
11 




U6 DISEASES OF WOMEK 

between the rectum and vagina was found to be normal to the touch, 
i. e., the hnes represented by the lower portion of the posterior vagi- 
nal wall and the outer surface of the pelvic floor, run- 
ning fi'om before backward, formed an angle as repre- 
sented in the accompanving diagram. 

Furthermore, when the introitus vaginge was re- 
tracted with a Sims's specuhim and the instniment re- 
moved, the muscles promptly contracted and firmly 
closed the vagina, showing that the muscles had been restored. 
This I consider to be the only rehable evidence of the success of this 
operation. 

Laceration of the Pelvic Floor, Sphincter-Ani Muscle, and Recto- 
Vaginal Septum. — In this extensive injury, in which the laceration 
of the walls of the rectum and vagina extends upward beyond the 
internal sphincter ani, it is necessary to restore the septum before 
operating upon the perinseum. As a rule, the laceration does not 
extend beyond the sphincters, and the parts can all be restored at 
one operation, but in the rare injury now under consideration, two 
separate operations are required. I will describe first the operation 
for restoration of the septum. The joatient should be placed in the 
lithotomy position, and the anterior wall of the vagina elevated by 
a Sims's or bivalve speculum, which exposes the parts to be treated. 
The tissues on each side of the laceration are vivified well out 
on the vagina, in order to obtain a broad surface for coaptation. 
Only enough of the mucous membrane of the rectum is removed 
to dispose of the scar tissue that may be present. Silk sutures 
are introduced with a round-pointed, curved needle, such as Emmet 
uses for vesico-vaginal fistula. The needle should be introduced 
at the outer edge of the vivified surface of the vaginal mucous 
membrane, and be carried deep into the tissues, and should emerge 
just within the edges of the rectal mucous membrane. By referring 
to Fig. 86 in colored plate an idea may be obtained of the sutures in 
position, with this difference — that in this operation silk sutures are 
used, and are tied upon the vaginal side, whereas in the operation of 
restoring the sphincter-ani muscle and perinseum, catgut sutures are 
employed, and these are tied upon the rectal side. The introduction 
of the sutures is begun above, and each one tied when introduced. 

The sutures should be Xo. 3 silk, and not more than an eighth 
and a sixteenth of an inch apart. They should be removed on the 
eighth day, and one month allowed to elapse before the next opera- 
tion is performed, in order to give the parts a chance to become 
firmlv united. 



PLATE I 




>r rf?^ 



F IG.S.i 
PAGE 14.7, 




.'S0l^ 



^^00- 



FIG. 84- 




^-.rr^f^r^yissiii^l^ieirr-;^: 



PLATE 1. 

Operation for Laceration of the Pekinjeum 
AND Sphinctek Ani. 

Figure 83. Page 147. 

The deprecsions on either side of the rectal wall show the 
ends of the sphincter ani. The rectum is drawn forward bj 
the levator. 



Figure 84. Page 147. 
Denudation complete. 



INJURIES TO THE PELVIC FLOOR. 147 



OPERATION FOR THE RESTORATION OF THE SPHINCTER 
ANI AND PERIN-aJUM. 

It has been already stated that the chief object of all plastic 
operations upon the pelvic floor should be to restore the muscles 
that have been injured. This is pre-eminently so in the operation 
to be described, because the sphincter ani is the most difficult to 
restore, and the results of failure are so apparent that neither the 
surgeon nor patient can possibly believe that the operation is a suc- 
cess when it is not — a delusion often indulged in regarding the plas- 
tic operations to repair the lesser injuries of the pelvic floor. 

In order to comprehend the position and relations of the surfaces 
to be vivifled, it must be borne in mind that when the sphincter ani 
is ruptured the severed ends are drawn outward and backward by 
the retraction of the muscle until they lie on either side nearly on 
a line with the posterior walls of the rectum. This may be better 
understood by referring to Fig. 83, colored plate. The depressions 
on either side of the anus are the ends of the muscle which are 
drawn down below the surface. 

The process of vivifying should be begun by seizing the end of 
the muscle on the patient's left. With the scissors a strip of tissue 
should be removed from that point around the tissues between the 
rectum and vagina, and downward and outward to and including 
the end of the muscle on the right. When this is done, it will 
sometimes be found that the softer tissues rise above the depressed 
end of the muscle, so that a fossa is formed on each side. Should 
this occur, more of the most prominent tissue should be removed. 
The denudation is then carried upward upon each side to the point 
where the laceration began. If there is much relaxation of the 
rectal and vaginal walls, the denudation may extend even higher on 
the sides. 

At this stage of the vivifying there are two broad denuded sur- 
faces (one on each side) connected by an isthmus formed by the 
recto- vaginal walls. In this septum all scar tissue should be cut away, 
and then the rectal and vaginal walls should be separated with the 
handle of a scalpel or blunt-pointed scissors. The object of this dis- 
section is to give a broader surface to be united, and to permit the 
vaginal wall to be raised up and attached to the inner side of the 
perineal body, as it is called. When the vi\dfying is completed, the 
parts appear as represented in Fig. 84, colored plate. There are or- 
dinarily two sets of sutures used, one to coaptate the rectal wall and 
sphincter-ani muscle, and the other to do the same for the perinteum. 



PLATE n. 

Operation for Laceration of the Perineum 
AND Sphincter Ani. 

Figure 85. Page 148. 
Sutures in the recto- vaginal septum introduced. 



Figure 86. Page 148. 
Sutures in the septum tied. The remaining sutures in place. 




PLATE II 



FIG. 85 

DAGE 14-8 



FIG. 86 




m 



INJURIES TO THE PELVIC FLOOR. 149 

fore tying tliem vivify all the rest of the parts to be united. The 
stitclies are introduced into the vaginal wall and the perineal stitches 
placed last. The patient is put into Sims's position and the rectal 
sutures are tied. She is replaced upon the back and the vaginal 
sutures are tied, and lastly those in the pelvic floor. 

I have obtained the very best results from this method of opera- 
ting, and in suitable cases prefer it to all others. Further details of 
the operations will be brought out in the following history of cases : 

Typical Case of LaceratioE extending through the Sphincter Ani.— ^ 
The patient was twenty-six years old when she was confined with 
her first child. The labor was tedious, and she was delivered, with 
forceps, of a very large child, which died during delivery. She 
made a rather slow recovery, ov^ing to the extensive injury to the 
floor of the pelvis. Five months after confinement I saw her for 
the first time. She was then in very good health, but suffered pain 
in the region of the injury, especially when she walked, and she had 
very little control of the rectum. When constipated, she suffered 
very little; but, when the bowels were free and when there was 
flatulence, she was obliged to remain secluded. 

I found that the laceration involved the sphincter-ani muscle, 
and evidently had extended upward into the wall of the rectum and 
vagina ; but union had taken place, by a little intervening scar tis- 
sue, down to the sphincter, or within a quarter of an inch of it. The 
muscles of the pelvic floor, excepting the sphincter and transver- 
sus peringei, acted well, and held the divided sides well up. The 
end of the rectum was also drawn upward and forward, so that the 
distance from the vestibule to the posterior margin of the anus was 
less than normal. This brought the posterior wall of the vagina up 
to the anterior, so that the vagina was closed. It was only by plac- 
ing the finger in the rectum and pressing it backward that the full 
extent of the laceration became apparent. She was constipated, and 
her tongue slightly coated, at this time. Pil. hydrarg., gr. x, and 
pulv. ipecac, gr. j, were given at bedtime, and a wine-glass of Hun- 
yadi-Janos water an hour before breakfast next morning. This 
moved the bowels freely, and they were kept free for the subsequent 
two weeks with the following ; 

Fluid extract of podophyllum 3 j ; 

Tincture of colocynth „ 3 i j ; 

Tincture of belladonna 3 j ; 

Glycerin o ^s. ; 

Syrup of acacia and compound tincture of cardamom, 
of each § j. 



150 DISEASES OF WOMEK 

A teaspoonful of this noon and evening before meals. When this 
acted too freely, only one dose was given. 

During these two weeks the nurse passed the finger every day 
into the rectum and pressed the parts back toward the coccyx, main- 
taining the traction steadily for several minutes. This was done for 
the purpose of restoring the elasticity of the tissues, and also elon- 
gating the divided sphincter muscle as much as possible. Menstrua- 
tion then began, and no further local treatment was employed until 
after it stopped, when it was resumed. Four days after the menses 
ceased, the operation was performed in the prescribed way, silk 
sutures being used. For twenty-four hours before the operation, 
and for three days after, the patient had only fluid food — beef -tea, 
strained soups, whey, and water. After the third day, peptonized 
milk, strained oatmeal and barley gruels, and raw oysters were added 
to the diet list. 

There was sufiicient pain during the first three days to require 
ten drops of liquor opii com p. to be taken every four hours. On 
the fourth day she suffered from fiatulence, which was relieved by 
catheterizing the rectum, using a silver catheter ; this had to be re- 
peated the following day. On the eighth day (and before the su- 
tures were removed) half an ounce of sulphate of magnesia in 
peppermint-water was given before breakfast and toward noon; 
when the patient felt the bowels inclined to move, haK a pint of 
solution of ox-gall and water were used as an enema. When this 
had been retained about twenty minutes, the nurse assisted the 
evacuation of the bowels by making pressure upon each side of the 
wound opposite the first suture, and, with the index-finger of the 
other hand in the vagina, she made gentle and interrupted pressure 
downward and outward. In this way it was hoped that the rectum 
would be evacuated without disturbing the wound. There was not 
the slightest trace of haemorrhage, which gave reason for believing 
that no harm had been done. 

On the ninth day all the sutures were removed, and on the tenth 
day the bowels were moved in the same way as before. During all 
this time the catheter was used to draw the urine. After this the 
patient was permitted to urinate in the prone position. Every second 
day until the twentieth the bowels were moved, the same care being 
taken by the nurse to guard the wound during the evacuation. On 
the twentieth day the wound was carefully examined, and there was 
apparently perfect union throughout, including the mucous mem- 
brane. The function of all the muscles of the pelvic floor was re- 
stored, except that of the sphincter ani. The function of that mus- 



INJURIES TO THE PELVIC FLOOR, 151 

cle was, however, sufficiently restored to give the rectum retaining 
power, but it did not act as a perfect sphincter muscle. When it 
acted, the contraction was not equally toward the center, but rather 
toward the point of rupture that had been restored. The posterior 
portion of the perineal body acted like a fixed point, toward which 
the muscle contracted. I am inclined to believe that this is the best 
result that can be obtained by this operation. After the new repara- 
tive tissue which is developed during healing has fully contracted, 
the function of the muscle becomes more nearly restored. Indeed, 
it is in many cases quite perfect so far as controlling the rectum is 
concerned, but it rarely, if ever, acts exactly as it did before injury 
— i. e., by a perfect concentric contraction. 

A Case illustrating Partial Failure of the Operation; a Second 
Operation completing the Cure. — The patient was thirty-five years 
old, and had had three children. The youngest was eighteen months 
old at the time when this history was taken. Her first labor, five 
years and a half ago, was complicated. The patient stated that the 
doctor in attendance said that there was a shoulder presentation, that 
the child was turned and delivered feet first, and that the forceps 
was used to deliver the after-coming head. From that time onward 
she had no control of the rectum, and the only way she was able to 
take care of herself was by being extremely constipated, the bowels 
never moving except in response to medicine, a dose of which she 
usually took about once every week. The extent of the injury was 
exactly like the case last given, excepting that there was union of a 
thin band of vaginal mucous membrane, which extended outward to 
the upper margin of the sphincter-ani muscle. There were also two 
hsemorrhoidal tumors, formed by hyperplasia of the rectal mucous 
membrane, located at each side of the anus. These haemorrhoids, 
which are not uncommon in this injury, were removed one month 
before the restoration of the lacerated parts was undertaken. The 
mode of operating was by seizing the tumors in a Pean forceps and 
making traction sufficient to raise the mucous membrane, then pass- 
ing the hsemorrhoid-clamp (Fig. 87) beneath the forceps, and slowly 




Fig, 87. — Haemorrboid clamp. 



152 DISEASES OF WOMEK 

constricting the pedicle bj tightening the clamp. A ligature of 
prepared silk was applied to the pedicle under the clamp. The for- 
ceps and clamp were then removed, the tumor clipped off far enough 
outside of the ligature to prevent its slipping, and the stump touched 
with carbohc acid. The ligatures came ofi in less than a week, leav- 
ing a verj minute spot to heal. She was then submitted to about 
the same preparatory treatment as in the last case related, and the 
operation was performed as before described. The diet was gruel 
and peptonized milk, with beef-tea. On the second day half an ounce 
of Rochelle salt was given, followed m three hours by an enema of 
half a pint of a solution of ox-gall, and, one hour later, a large ene- 
ma of soap-suds. This did not move the bowels ; on the following 
morning half an ounce of castor-oil was given, and in the afternoon 
the enema repeated as on the previous day ; the enema came away, 
but the bowels did not move. The next day, she was ordered a 
mixture composed of a decoction of senna, one ounce to a pint of 
water, with one ounce of Rochelle salt. Of this, two ounces were 
given every hour until she had taken three doses. It produced a 
free evacuation, without causing pain in the wound or doing it any 
harm. The mixture was repeated in the same way with a like effect, 
and was again ordered a third time, but, by an oversight of the nurse 
(the case was in a general hospital), it was not given. Another 
mistake was made the following day, the nurse giving two drachms 
in place of two ounces of the medicine. On the eighth day after 
the operation the medicine was given correctly ; but, when the bowels 
were about to move, the nurse, who should have supported the parts, 
was absent, and the patient got out of bed to use the commode, and 
had a free movement, attended with pain and some bleeding. Up to 
this time the wound had progressed quite well in healing, but that 
unfortunate movement of the bowels, unaided by the nurse, tore the 
ends of the sphincter-ani muscle apart, and spoiled the operation to 
that extent. On the tenth day the sutures were removed. There 
was perfect union, excepting the ends of the muscle. The opera- 
tion was a complete failure, so far as its main object was concerned. 
She was kept in the hospital for two days more, when it was found 
that, although her bowels were easily kept regular — a great improve- 
ment on her former state — she had very little more control of the 
rectum than before the operation. 

Three months after this she was again persuaded to try to obtain 
relief, and she was placed under the care of a more competent nurse^ 
who followed directions regarding preparatory treatment, including 
the manipulation daily of the sphincter ani, and at the end of a week 



INJURIES TO THE PELVIC FLOOR. 153 

another operation was performed to restore the sphincter. The 
stretching of the muscle backward with the finger in the rectum as 
practiced by the nurse was more effectual than in cases in which the 
rupture is complete. The part of the pelvic floor which was restored 
by the operation gave some support to the severed ends of the sphinc- 
ter, so that when traction backward was made the muscle became 
considerably elongated ; and when the second operation was under- 
taken the parts were sufficiently relaxed to facilitate the necessary 
manipulations. 

The patient, well angesthetized, was placed in Sims's position, a 
email speculum introduced into the rectum posteriorly, and traction 
made backward, while with a strong tenaculum, fixed in the margin 
of the anus anteriorly, the ends of the muscle and the intervening 
tissues were brought into view. The end of the muscle of the left 
side was seized in the tissue forceps and denudation made from the 
left to the right end of the muscle. The vivifying included both 
ends of the muscle and extended upward on the anterior rectal wall 
about half an inch. The sutures, three in number, were introduced 
in the same way as in the first operation. Some trouble was ex- 
perienced in curving the needle around through the tissues, but with 
the aid of an assistant, who passed his index-finger into the vagina 
and everted the rectum in front, all the sutures were accurately in- 
troduced. 

On the third day after the operation a dose of senna and salts 
was given in the morning, and at noon the bowels were moved in a 
rather novel way. An apparatus constructed upon the principle of 
that used by Professor Bigelow for expelling fragments of stone 
from the bladder was employed to wash out the contents of the rec- 
tum (Fig. 88). 




Fig. 88. — a is a hard-rubber rectal tube bifurcated at b c ; b, whicli is the supply tube, 
is attached to a fountain syringe, and c connects with the evacuator, composed of a 
soft-rubber bulb, with an escape tube. In other words, it is a large reflux catheter 
with a rubber bulb in the escape tube for the purpose of facilitating the outflow. 

Two nurses use this instrument as follows : One passes the tube 
into the rectum, carefully making continuous pressure backward to 
avoid pressing upon the edges of the wound, while the other nui-se, 



154 DISEASES OF WOMEN. 

closing the escape tube and opening the stop in the fountain syringe, 
injects the solution of soap and water. When half a pint has been 
introduced, the supply is cut off and the evacuation tube opened. 
If the contents of the rectum do not flow out, the bulb is pressed 
and relaxed after the manner of using a Davidson's syringe. This 
process is repeated until the bowels are freely evacuated. The bow- 
els were moved in this way until the twelfth day (the sutures were 
removed on the ninth) ; after that the bowels were moved daily by 
the senna and salts. At the end of three weeks the restoration of 
the muscle was as perfect as could be, and the patient was dismissed 
with complete retaining power. 

This case illustrates the danger there is of the ends of the sphinc- 
ter muscle being toi-n apart when the bowels are moved. A skilled 
nurse, well used to the management of such cases, can do much to 
avoid this unfortunate accident, and yet when all care is exercised it 
will often happen. In order to avoid this, several ways have been 
tried. Keeping the bowels confined for ten or twelve days was the 
fashion for a long time. More recently some operators have kept 
the bowels free by laxatives that rendered the contents fluid and pro- 
cured an evacuation every day after the second day from the opera- 
tion. I have tried both, and now prefer the reflux-catheter evacuator 
when a nurse can be obtained who knows how to use it. When 
this is net possible, I prefer to keep the contents of the bowels solu- 
ble and to move them every second day — beginning on the third day 
after the operation. 

When union is obtained, excepting of the sphincter muscle, as in 
the case just related, and a second operation is performed, some op- 
erators prefer to begin de novo^ dividing the united portion and then 
proceeding as in the primary operation. I much prefer to keep all 
that has been gained and to restore the sphincter in the way already 
described. I was first induced to adopt this method in a case that 
had been twice operated upon before it came to me wdth the result 
of restoring all but the sphincter. So much tissue had been removed 
that I dared not risk a possible complete failure, hence I attempted 
to restore the sphincter in the way just described, and with success. 
My second case of this kind was one in which complete laceration 
occurred during labor ; primary union, without sutures, of the peri- 
neal body took place, but not of the sphincter. Since then I have 
repeatedly operated successfully in such cases of partial failure in my 
own practice and that of others. 



INJURIES TO THE PELVIC FLOOR. 155 

OPERATION FOR RESTORATION OF THE PELVIC FLOOR IN 
SUBCUTANEOUS LACERATION BETWEEN THE VAGINA AND 
RECTUM. 

This operation is the same as when the laceration involves the 
skin and mucons membrane also, excepting that the whole of the 
skin and mucous membrane occupying the position of the perineal 
body is removed. Before beginning the denudation the tissues in 
front of the sphincter should be seized between the thumb and finger. 
This will indicate the extent to which they should be removed., 
While the parts are thus held in the finger and thumb, or with a 
tissue forceps, the whole mass should be removed with one sweep of 
the curved scissors. After this is done, if there is still some loose 
tissue lying over the muscular structures below and on either side, it 
should be removed. The sutures are introduced as in the ordinary 
operation, special care being taken to pass the sutures deep into the 
muscular tissues, and to use plenty of them. At the present time I 
see accounts in the journals of restoring the perinaeum with one su- 
ture. I have seen some of these so-called restorations, and found 
the results utterly useless. 

A Typical Case of Subcutaneous Laceration, belonging to the Sec- 
ond Class described in the Classification. — This patient was the wife 
of a physician ; I give the history as I obtained it from her hus- 
band. 

The patient was thirty-three years of age, the mother of two chil- 
dren ; the first born on March 29, 1880, and lived eleven hours; sec- 
ond born September 9, 1881, now hving; and one miscarriage since 
the operation in February, 1884. 

The first labor was tedious, lasting from Friday at 8 a. m. till 
Monday at 2 p. m. — seventy-eight hours, but accompanied with no 
after ill-effects of any note. In the second labor, though it was 
normal in duration, from its inception until the completion of the 
first stage it was observed that the presenting head was very low in 
the pelvis, resting upon the posterior wall of the vagina, while the 
cervix was directed toward the hollow of the sacrum, and was un- 
evenly dilated, the anterior lip being much thicker than the posteri- 
or. As the head descended toward the vulva the recto- vaginal tis- 
sues were pushed before it and extended beyond the vulva on the 
perinseum. The anterior segment of the cervix, descending in front 
of the head and tightly grasping it, had to be pushed upward in the 
interval between the expulsive pains and held until complete exten- 
sion occurred and the delivery was completed. Xothing of note 



156 DISEASES OF WOMEN. 

transpired during the lying-in period of sixteen days, excepting great 
difficulty in moving the bowels. 

Upon taking an upright position, it was found that the protrusion 
or prolapse which was noticed at the time of delivery w^as still pres- 
ent, and complaint was made of the feeling that '' everything was 
falling out " ; from this time onward defecation could only be accom- 
plished by pushing the protruding mass well back into the vagina. 
Her subsequent health was bad ; rapid loss of flesh and strength fol- 
lowed ; nervous prostration, impaired digestion, and loss of appetite su- 
pervened, totally incapacitating her for her usual duties. One month 
after confinement she had a very painful attack of mastitis, which, 
however, did not go on to the stage of suppuration, but further pros- 
trated her, accompanied as it was by aphtha, ulceration of the cornea, 
facial neuralgia, etc. These sequelae, together with over-lactation, car- 
ried on for fourteen months, naturally first retarded and then pre- 
vented the proper involution of the pelvic organs ; and the prolapse of 
the recto- vaginal wall, dragging down the heavy uterus, caused constant 
distress, pain, and suffering, both physical and mental. Constipation 
of the most intractable kind now existed, and the bowels could only be 
evacuated by liquefying their contents with purgatives aided by enemas. 

Examination made twelve months after confinement revealed a 
slight prolapse of the anterior vaginal wall, bladder, and urethra, and 
extensive prolapse of the posterior wall, which caused the rectum to 
be drawn forward through the ostium, forming a sacculus. The 
uterus was three and one fourth inches in depth and retroverted. 
The mucous membrane of the vagina and the integument of the 
pelvic floor presented no appearance of having been ruptured at any 
time, but there was not a sign of any muscle or fascia in the center 
of the space between the vagina and rectum. 

May 10^ 1883. — (The operation was performed in the way de- 
scribed above. The following is added to the doctors report by the 
author.) 

After rallying from the anaesthetic, great pain at the seat of the 
upper stitch was complained of, necessitating the free use of opium 
to allay it. For eight days the urine was drawn by catheter, the 
patient being unable to void it at any time when lying in the dorsal 
position. Twenty-four hours after the operation the bowels were 
readily moved by a single enema, and for several days acted without 
resort to any provocative. Two of the sutures were removed on the 
eighth day and the others on the tenth day. Perfect union existed 
throughout, and three weeks from the day of the operation the pa- 
tient was up and around the room. 



INJURIES TO THE PELVIC FLOOR. 157 

From this time on the improvement in every particular has been 
rapid and uninterrupted, with an entire disappearance of the pro- 
lapse, though the uterus remains considerably retroverted, which 
position it had occupied for years before the marriage of the patient. 
At this time, fourteen months after the operation, there has been no 
return of the former trouble, though she performs all her domestic 
duties and can exercise without fatigue or distress. At the time of 
making this report she weighs over twenty pounds heavier than she 
did one year ago, and to every appearance is in perfect health. 

Median Laceration down to the Sphincter Ani, complicated with 
Temporary Relaxation of all the Muscles of the Pelvic Floor, and Pro- 
lapsus of the Recto-Vaginal Walls. — The patient was twenty-seven 
years old, well developed, and in good general health. She had been 
married four years. She had had two children, the first sixteen 
months old and the second iive months. Her second labor was 
tedious and difficult ; the cause unknown. Two weeks after her last 
confinement she entered actively upon her household duties, and 
very soon afterward began to suffer from pelvic tenesmus, which was 
much aggravated by the erect position. Being of an active dispo- 
sition, she persisted in attending to her duties until her discomfort 
became so great that she was obliged to seek relief. When first ex- 
amined, she said that in standing and walking she was tormented 
with a feeling of dragging downward in the pelvis, and lately had 
felt " something protruding from the vagina w^hile in the erect po- 
sition." Her bowels had usually been regular, but lately she noticed 
that they moved with difiiculty, as if there was some loss of expelling 
power, and when voluntary efforts were made to evacuate the rectum 
the recto-vaginal walls protruded. 

All these symptoms were much relieved upon lying down. She 
weaned her child when it was three months old, because she had not 
much milk, and her friends made her believe that her suffering was 
due to nursing. At the fourth month she menstruated, but, not 
being any better, she sought advice. The laceration was found to 
be as already stated. The transversus-perinaei muscles were still 
attached to the sides of the laceration, and by drawing the pai-ts out- 
ward the vagina was distended laterally as well as antero-posteriorly. 
The distance from the vestibule to the anus was increased by the 
downward and backward displacement of the posterior portion of 
the pelvic floor. The posterior rectal wall and the anterior vaginal 
wall were found lying upon the sphineter-ani nnisele, and when 
the patient coughed or strained they protruded a little beyond the 
line of the anus. There was also commencing prolapsus of the base 



158 DISEASES OF WOMET^. 

of the bladder and anterior vaginal wall. By passing a large sound 
into the rectum it was found that the recto-vaginal walls, imme- 
diately above the sphincter-ani muscle, were very thin, indicating 
that the muscular coat of the vagina had been torn longitudinally, or 
else that its attachment to the muscles of the pelvic floor had been 
severed ; perhaps both injuries had occurred. 

The patient was prepared for the operation in the same way as 
in the case just related. The denudation was made in the usual man- 
ner, but was carried upward on each side nearly haK an inch above 
the outline of the scar of the original laceration and about three 
quarters of an inch broad from without inward. The mucous mem- 
brane was also removed upon the vaginal wall up to the point where 
it came in contact with the anterior vaginal wall ; that was made the 
apex or most prominent point of the vivifying. This was much be- 
yond the limits of the laceration. The object in vivifying the tis- 
sues so high up on either side was to secure the ends of the bulbo- 
cavernosus muscle in the wound in order to reunite them, and for a 
like reason the vivifying was made high up on the vaginal wall in the 
hope of uniting its muscular coat to the muscles of the pelvic floor. 
When the parts to be united were vivified it was found that all that 
remained of the vaginal wall at that point had been removed, leaving 
nothing but the rectal wall. This was not owing to having removed 
too much tissue, but because the muscular coat of the vagina had 
been destroyed by the original injury. There was free haemorrhage, 
especially from the veins in the deep portion of the wound, but the 
sutures controlled it. The first suture was passed around wholly 
within the tissues, but the next ones were passed deep in on one 
side, then out and across in front of the rectum, and finally through 
the other side, the object being to bring the sides of the wound to- 
gether in front of the rectum. The fifth and sixth sutures were 
passed through each side and through the middle coat of the vagina, 
and the seventh through the sides only. 

After tjnng the sutures and placing marine lint over the wound, 
an abdominal bandage was applied, and a narrow perineal bandage 
attached to it and fastened rather firmly. When the patient recov- 
ered from the ether she had vomiting, which lasted into the night ; 
she also had sharp pain, which, toward the morning of the following 
day, was accompanied with severe rectal tenesmus. This prevented 
her from sleeping, and made her quite weary. The pain and tenes- 
mus were caused, I am sure, by the fact that one or more of the 
sutures was passed through a portion of the rectal wall. I took 
pains to avoid the rectum, but must have failed to do so altogether. 



INJURIES TO THE PELVIC FLOOR. 159 

A suppository of morph. siilph. and ext. belladonnse, each a fifth of 
a grain, was used night and morning to relieve the pain, which did 
not subside wholly until the morning of the fourth day. She took 
very httle nourishment— nothing solid until the fifth day. On the 
evening of the fourth day she had a dose of pulv. glycyrrhizse 
comp., and at noon on the fifth day an enema ; this moved the bow- 
els, and from that time they were kept regular by the same means. 
After the second day the perineal bandage was removed altogether 
and the lint-dressing continued. On the fifth day after the bowels 
moved there was a slight discharge from the vagina containing 
traces of pus. She was then ordered a vaginal injection of sul- 
phate of zinc, sixty grains to a quart of warm water, given with 
the fountain syringe at low pressure, so as not to distend the vagina 
too much. This was continued once a day until the eighth day, and 
after that twice a day for another week. She was unable to urinate, 
and hence the catheter had to be used until the tenth day after the 
operation. This gave rige to a slight cystitis ; it was treated by a 
teaspoonful of sweet spirits of niter in a small glass of flaxseed-tea 
every ^ve hours, continued for three days. The sutures were re- 
moved on the tenth day, and union appeared to be complete. She 
was not permitted to leave the bed until the eighteenth day. The 
vaginal douche of zinc solution was continued up to the next men- 
strual period, and then discontinued. After the flow ceased, the 
douching was resumed, and continued for two weeks longer. 

She was examined two months after the operation, and the re- 
sult was found to be perfectly good. 

Laceration of the Levator-ani Muscle and Laceration in the First 
Degree in the Median Line of the Pelvic Floor. — The patient was 
thirty-four years old, and had three children — the eldest ten and the 
youngest three years of age. The last child was delivered with for- 
ceps, and she dates her trouble from that time. She gave the symp- 
toms of displacement of the pelvic organs in a marked degree. 
Standing and walking caused great distress. She was constipated, 
and had great difiiculty in evacuating the bowels. She felt that the 
rectum had lost its expelling power, and, when she made voluntary 
efforts during defecation, the vaginal walls protruded. 

The laceration in the median line was not more than half-way 
down to the sphincter-ani muscle, but the parts were relaxed, and 
both vaginal walls prolapsed. The uterus was also retroverted and 
low down. There was complete separation of the transversus-peri- 
naei muscle, and the bulbo-cavernosus muscle was either lacerated 
or else overstretched, so that it was functionally imperfect. The 



160 DISEASES OF WOMEN". 

posterior half of the pelvic floor was displaced downward, and the 
levator-ani muscle did not contract on being stimulated. The touch 
also showed that the levator had apparently become atrophied. Rest 
in the recumbent position for two weeks, and support of the pelvic 
floor and uterus bj a tampon in the vagina and a perineal bandage, 
did not restore the tonicity of the pelvic floor sufiiciently to encour- 
age a continuation of that treatment. It was now evident that the 
levator ani could not be restored. I then decided to operate with 
the hope of restoring the bulbo-cavernosus and transversus-peringei 
muscles and indirectly uniting them to the sphincter ani, to com- 
pensate, as far as possible, for the loss of the levator. 

The operation was the same as that performed for subcutaneous 
laceration in the median line, excepting that all the tissues were re- 
moved down to the sphincter ani, and the denudation was carried 
high up in the posterior vaginal walls and on each side. Care was 
taken to support the pelvic floor during the healing process, and the 
nurse protected the parts with counter-pressure when the bowels 
moved. Good union was obtained, and at the end of a month it 
was evident that the muscles had been restored, excepting the levator 
ani. The loss of this muscle was, to a considerable extent, compen- 
sated for by the restoration of the other muscles, but there was still 
sagging of the posterior part of the pelvic floor. The patient was 
not permitted to walk or stand much for a month, and the retro- 
verted uterus was kept in place with a pessary. She was greatly re- 
lieved, but, at the end of a year, she was still unable to take her full 
share of active exercise without supporting the parts with a perineal 
bandage. With the aid of this support her usefulness was nearly 
restored, but she was not cured completely. 

Atrophy and Permanent Paralysis of the Muscles of the Pelvic 
Floor. — The patient was forty-three years old when first treated; 
she had borne two children, the youngest being fifteen years old, and 
had had a large number of miscarriages. Her first labor was tedious 
and instrumental, but she made a fair recovery. "When first seen 
there was a general sagging of the pelvic floor, great distention of 
the Yulva, rectocele and cystocele, and prolapsus of the uterus. 
There had been a very slight median laceration of the skin and mu- 
cous membrane, and evidently complete subcutaneous laceration of 
the muscles at the median line. At that time, fourteen years ago, I 
did not understand the nature of such cases, hence I followed the 
authorities and treated her in the usual way. She was placed in bed 
and the pelvic organs kept in position, and, when the parts had ap 
parently improved in nutrition sufiiciently to give prospects of heal 



INJURIES TO THE PELVIC FLOOR. 161 

ing, tlie usual operation was performed. The result was apparently 
aU that could be desired when the sutures were removed. So far as 
the shape and quantity of tissue was concerned, the perineal body was 
restored, but it proved to be functionally useless. As soon as the 
patient returned to her usual habits of hfe the vaginal walls and 
uterus began to descend and put the central portion of the floor 
upon the stretch, which caused pain in the scar tissue, so that she 
suffered more than before the operation. The perineal body became 
thinned by distention until it was only a band not more than a quar- 
ter of an inch thick, stretching across from one side of the distended 
vulva to the other. Traction upon this band, of scar tissue mostly, 
caused by the protruding vaginal walls, gave such acute pain upon 
standing or walking that it was necessary to incise the parts. It is 
needless to say that she was not improved by the treatment. She 
passed from under my observation, but I learned that about a year 
afterward she was again operated upon by another surgeon with no 
better results, l^early five years after my treatment she was found 
among the incurables. 

Rigidity of the Muscles of the Pelvic Floor from Inflammatory 
Sclerosis. — The patient was a delicate blonde, twenty-five years old. 
She had measles at twelve years of age, and at that time had some 
inflammation in the region of the pelvic floor which terminated in a 
discharge of pus from the vagina. Ever since then she has had 
lencorrhoea. At puberty the menses appeared, and have continued 
normal. She was married six months before I first saw her. Coitus 
was found to be impossible, and all efforts to accomplish it caused 
her great pain. An examination revealed the fact that she had 
catarrh of the cervix and a vaginitis such as occurs in the strumous 
diathesis. The muscles of the pelvic floor were rigid and tender to 
the touch. It was presumed that, when the inflammatory disease of 
the cervix and vagina was relieved, she might be capable of fulfilhng 
her social functions, but such was not the case. Nitrous-oxide gas 
was used to produce anaesthesia, and, with a Sims's speculum, the 
vulva was distended sufficiently to temporarily paralyze the muscles. 
Some laceration of the mucous membrane at the vulva also occm-red, 
but when this healed the rigidity and tenderness of the pelvic floor 
were sufficiently relieved to permit the sexual function. About two 
months afterward the tenderness and rigidity of the muscles returned 
to a slight extent, but were promptly and permanently relieved by 
a repetition of the forcible distention with the speculum. Several 
years have passed since this treatment was employed, but there has 
been no return of the trouble. 

12 



CHAPTER YIII 

FISTULA EST ANO AND COCCYODrNIA. 

FISTULA IN ANO. 

Fistula in ano in women differs in no wise from the same affec- 
tion in men, so far as its pathology, symptoms, and physical signs are 
concerned ; and, as these are fully described in treatises on surgery, I 
shall treat of them here only incidentally. But the treatment of fistula 
in women has some important peculiarities connected with it, and I 
propose, therefore, in this chapter to deal with the subject of treat- 
ment alone, giving special attention to those points of difference as 
I have observed them in the two sexes. 

Having had several very unsatisfactory results in treating fistula 
in ano according to the usual methods of surgery, I determined some 
years ago to seek other means better adapted to the relief of that 
affection of the rectum. The history of my own failures, and those 
which I have seen after treatment by other surgeons, may be the 
best introduction to what I have to say on this subject. My first 
case, treated in hospital, was a dissipated woman, who did not know 
her age, but appeared to be about sixty. She had a very severe 
purulent vaginitis, presumed to be a neglected gonorrhoea, and also 
a fistulous opening extending from the side of the perinseum, about 
three quarters of an inch from the mesial line, into the rectum above 
the sphincter muscle. When the vaginitis was relieved, I treated 
the fistula by laying it open in the usual way and placing some lint 
in the wound so as to make it heal by granulation from the bottom ; 
in this I was disappointed. The divided surfaces slowly healed over, 
but did not unite by intervening granulations or by new tissue. 
The result was that the divided ends of the sphincter muscle were 
never united, and the patient lost the retaining power of her rectum. 
During the healing process applications were made to the parts, in 
the hope of exciting proliferations to fill in the space, but without 
avail. The patient, a disgusting creature to begin with, became 
much worse after the operation. 



FISTULA IN ANO AND COCCYODYNIA. 163 

Wliile I was thinking of some way to restore her sphincter, she 
was granted leave of absence from the hospital one afternoon, and, 
promptly getting drunk, was arrested and sent to jail next morning 
by the police justice, who remembered her of old. What her sub- 
sequent history was I do not know, but I do know that I felt relieved 
when I heard of the disposition made of her by the judge. 

The next case of fistula occurred in private practice ; it was that 
of a young lady who broke down from over- taxation and dysmenor- 
rhoea. She had a pelvic abscess and finally a fistula, which I was 
called upon to treat after her physician had partially restored her 
health. The external opening of the fistula was situated in the an- 
terior and lateral portion of the perinseum. Owing to my experience 
with my hospital patient I was unwilling to operate in the same 
way, but gladly decided to employ the elastic ligature, strongly rec- 
ommended at that time in the treatment of fistula. Accordingly, I 
passed the ligature through the canal, and, bringing the end out 
through the anus, tied it rather tightly. Considerable pain, which 
caused my patient great suffering, followed, and lighted up many of 
the old nervous symptoms from which she had just recovered. The 
ligature cut its way outward rather too rapidly, perhaps, and in six 
days all the tissues were divided except a very small portion of the 
skin, which I snipped with scissors. The parts healed over, but the 
ends of the sphincter muscle did not unite. In fact, the result was 
about the same as in my hospital case. For a long time the retain- 
ing power of the rectum was completely lost. Two years after the 
operation I examined her, and found that the contraction of the scar 
tissue had brought the ends of the muscle nearer together, but still 
the function of the sphincter was imperfect. The patient was un- 
able to retain fiuid fseces or gas, although when slightly constipated 
she experienced very little trouble. 

Two other cases have come under my observation, in which the 
conditions presented were very much like those described in my own 
cases. 

The first one was a lady, thirty-two years of age, married for ten 
years, and sterile. For three years she had suffered from a painful 
growth at the meatus urinarius ; this gave rise to so great tenderness 
as to prevent coitus and to cause distress during micturition. The 
tumor was removed and the parts healed well after the operation, 
but still she had symptoms of vaginismus which compelled her to 
return for further treatment. A careful examination revealed the 
following condition : The perin^eum was shorter than normal, and 
was drawn upward by the action of the sphincter-vagim^ muscle 



164: DISEASES OF WOMEN". 

until it nearly closed the introitiis vaginse. The rectum appeared tc 
be also drawn forward, so that the distance from the posterior wall 
of the rectum to the meatus minarius was altogether shorter than is 
usually found. A scar was formed on the right margin of the anus. 
The function of the sphincter ani was impaired. Upon inquiry, I 
learned that seven years before she had been operated on for fistula, 
and had never since had complete control of the rectum. 

The other case referred to so closely resembled in history those 
just given that it need not be related in full. The only point of 
difference was that this patient sought advice regarding her want of 
control of the rectum. It will be observed that in all four of these 
cases the fistulae were situated either upon the anterior or lateral 
margins of the anus. A question here arises, whether the operation 
for fistula situated naore toward the posterior margin of the rectum 
would terminate in the same unfavorable way. This I can not an- 
swer, as I have never seen a case ; I can not, however, see any reason 
why it should not do so. I am not disposed to believe that the re- 
sults obtained in the operation for fistula in ano are always so unfort- 
unate as in the cases recorded here. If that bad proved to be the 
case, the attention of surgeons would have been given to the subject 
long ago. 

That the power of the sphincter-ani muscle is lost in a large 
number of cases after the operation is, I believe, a fact. I might go 
further than this and say that, in all cases in which the fistula is lo- 
cated completely outside of the muscle, and it is therefore necessary 
to divide the sphincter in operating, there is great danger that it will 
not be fully restored. The divided muscle retracts, and the space 
between its ends is filled in very slowly with new tissue ; as a result, 
there is usually a large amount of scar tissue necessary to connect 
the two ends. This must impair its functions, if it does not entirely 
destroy it. 

In a healthy subject in whom the termination of the fistula does 
not extend far outward, and the induration of the tissues around the 
canal is not extensive, the healing process may go on rapidly, thus 
connecting the ends of the muscle by means of intervening new tissue. 
Under such circumstances, the function of the muscle may be re- 
tained ; on the other hand, if the fistula extends from high up in the 
rectum to a point some distance outside of the muscle, the operation 
is almost sure to be a failure. Of course, the greater the amount of 
tissue between the rectum and the fistula, the farther will the ends 
of the muscle be separated by retraction, and the longer v^U the 
parts be in healing. In such cases the function of the sphincter is 



FISTULA IN ANO AND COCCYODYNIA. 165 

very liable to be impaired. When the fistula is located beneath the 
mucous membrane only, then a perfect result can always be obtained* 
Mr. John Gray ("Lancet," December 11, 1880) states that operative 
treatment should be deferred until the walls of the abscess, as well 
as the consequent fistulous tract, have assumed a condition of health 
and a disposition to take on a healing process. This is certainly a 
good rule in surgery, because it secures, as far as possible, the con- 
dition necessary to prevent fecal incontinence. In order to avoid 
such unfavorable results, it was evidently necessary to operate with- 
out dividing the sphincter muscle, or, if that were impracticable, to 
secure union of the divided ends of the muscle with the least possi- 
ble quantity of intervening new tissue. 

In the hope of curing the fistula without dividing the sphincter, 
the following method was adopted : An incision was made through 
the skin and lower part of the sinus large enough to admit two fin- 
gers below and one at the upper end of the wound. The edges of 
the wound were held apart with retractors, and the opening in the 
rectum was found and brought into view by passing the finger into 
the rectum and everting the rectal wall through the wound. The 
edges of the opening in the rectal wall were then pared with the 
scissors, and two or more catgut sutures were introduced and tied. 
The external edges of the wound were kept apart by a pledget of 
carbolized lint, which was changed every day until the wound healed. 
The idea was to first convert a complete fistula into a blind external 
one, and then finish the cure by compelling the external sinus to heal 
from below outward. To prevent any strain upon the sutures by 
distention of the rectum, I paralyzed the sphincter by overdistention, 
and kept the bowels free by saline laxatives. Of two cases treated 
in this way one wa^ a success and the other only partially so, as 
the opening into the rectum closed, but a blind external fistula re- 
mained. 

Regarding this method of treating fistula, I can only say that the 
danger of losing the sphincter muscle is avoided, which is very im- 
portant, but there are objections to it. The operation is difiicult to 
perform— at least the closing of the opening in the rectum with sut- 
ures is not easy — and, then, my impression is that it will fail to cure 
some cases. 

While thinking of some other method of treatment more satis- 
factory than that given above, I noticed a suggestion in the " Chicago 
Medical Eeview," by Dr. Dudley, to lay open the fistula, trim oft' 
the indurated tissues along its track, and treat as a lacerated perinanim, 
with sutures. It occurred to me that this method was deservino- of 



166 



DISEASES OF WOMEN. 



a trial, and I determined to put it to the test of practice as soon as I 
could get an opportunity. It was, of course, impossible to tell what 
the results would be, but I thought that it promised as much as the 
methods which I had used. Such an opportunity presented itself to 
me, and the result will be seen in the following history : 

Fistula in Ano successfully treated by tlie New Method. — The pa- 
tient was a married lady, who had anteflexion of the uterus, which 
caused sterility. On two occasions she had dysentery, which left a 
tender condition of the rectum and haemorrhoids. While under 
treatment for the flexion of the uterus, she had an abscess on the 
right side of the anus, which terminated in the formation of a com- 
plete fistula. The 
external opening 
was about an inch 
from the anus on 
the right side, and 
the internal open- 
ing was immedi- 
ately above the 
sphincter-ani mus- 
cle. 

There was the 
usual exudation 
around the fistu- 
lous tract, but it 
was not so exten- 
sive as in many of 
these cases. The 
rectum having 
been thoroughly 
washed out with 
disinfectants, after 
a free evacuation 
of the bowels, a 
bivalve rectal spec- 
ulum was intro- 
duced and the fis- 
tula laid open. The 
scar tissue was care- 
fully dissected out, 
and special care was taken to vivify the mucous membrane around 
the upper opening of the fistula. The ends of the sphincter muscle 




Fig 



89. — The operation for fistula ; the tract laid open and the 
sutures in place, a, anus ; f, outer end of fistula. 



FISTULA m ANO AND COCCYODYNIA. 167 

retracted, so tliat it was necessary to remove a corisiderable portion 
of the mucous membrane and cellular tissue in order to expose the 
ends of the muscle in the edges of the wound. Fine silk sutures 
were then introduced into the mucous membrane of the rectum, the 
lower ones being made to include the sphincter-ani muscle. 

Deep sutures were then introduced from the outside upward in 
the same manner as in the operation for restoring the perinseum. 
Fig. 89 shows the sutures in place. The deep sutures were tied first. 
and the slight traction upon them drew the tissues downward and 
shortened the length of the wound very much. This brought the 
sutures in the mucous membrane very near together. I should have 
stated that before the fistula was laid open the sphincter-ani muscle 
was stretched until paralyzed ; this prevented any tension upon the 
sutures for the first few days. 

The bowels were moved daily, and after each evacuation the rec- 
tum was washed out with carbolized water. There was a little sup- 
puration in the track of one deep suture, but union was complete in 
ten days. The deep sutures were removed on the ninth day, and 
the sutures in the mucous membrane were removed at the end of 
two weeks. 

The recovery was perfect, the function of the sphincter muscle 
being fully restored. 

COCCYODYNIA. 

This affection was first described as a neuralgia of the coccyx by 
Dr. E"ott in the '' ]^orth American Medical Journal," May, 1844, 
but it attracted little attention until 1861, when Sir James Y. Simp- 
son revived the subject and gave it the name which it now bears. 

Pathology. — Pain upon moving the coccyx and contracting the 
muscles attached to it is the chief characteristic of this disorder. 
The morbid conditions found are variable. Fracture and dislocation 
of long standing and caries of the coccyx have been discovered in 
some cases ; in others, no appreciable lesions can be detected. It is 
presumed that, in the absence of structural changes of the bone and 
muscles, the pain may be due to rheumatism of the tendons of the 
muscles or neuralgia of the nerves distributed to them. 

Symptomatology. — There is little or no suffering while the pa- 
tient is at rest, but upon rising, sitting down, or evacuating the. bow- 
els, pain over the coccyx is experienced. Sitting is painful in some 
cases, owing to pressure upon the bone. Any sudden movement is 
attended with suffering. Some patients are unable to rise from a 
low seat without assistance. 



168 DISEASES OF WOMEX. 

Physical Signs. — Tenderness upon pressing and moving the coc- 
cyx is the chief diagnostic sign. Painful haemorrhoids, lissure of 
the anus, and spasm of the adjacent muscles caused by ascarides in 
the rectum, may be mistaken for this affection, but they can be ex- 
cluded by physical examination. 

Prognosis. — Some cases of coccyodynia are slight, and wear away 
in time without special treatment ; but, though the disease may not 
perceptibly injure the general health of the patient, it is often of such 
long duration, and occasions so much suffering and inconvenience, 
that it is necessary to resort to surgical means for relief. 

Causation. — Women who have borne children are the most fre- 
quent, though not the only, sufferers from this disorder. Injuries 
sustained in parturition, or blows upon the coccyx, exposure to cold, 
and diseases of the ovaries and uterus, are its chief causes. 

Treatment. — The surgical methods of treatment are those prac- 
ticed by Prof. Simpson and Dr. Nott. Neither of them is danger- 
ous, and one or the other is certain to give satisfactory results. 

By Prof. Simpson's method an ordinary tenotomy-knife is in- 
serted at the lowest point of the coccyx, and passed ilatwise between 
the skin and cellular tissue till its point reaches the junction of the 
sacrum and coccyx. Then the knife is turned and withdrawn, mak- 
ing a subcutaneous incision which entirely severs the muscles over 
one side of the coccyx. The same operation is repeated on the other 
side, ^o haemorrhage is to be feared in subcutaneous operations 
unless some large vessel should be cut. 

An easier operation, and one more likely to effect a cure, is 
performed by exposing the coccyx through an external incision, 
raising the extremity of the bone, and severing the muscles with a 
pair of scissors. The subcutaneous operation, always difficult, is 
nearly impossible where the bone is covered with much adipose 
tissue. 

Should the bone itself be diseased, section of the muscles would 
not effect a cure. In such cases the coccyx must be laid bare, dis- 
articulated by the knife, and amputated, according to the method of 
Dr. IN^ott. 

The complete removal of the coccyx is the only method which 
has proved satisfactory in my practice. Kott's method of operating 
is to expose the coccyx, detach the muscles, and then take it off' from 
the sacrum with the bone-forceps. In this operation there is danger 
of injuring the sacrum, and causing a subsequent necrosis. I there- 
fore prefer to disarticulate with the knife or scissors, cutting through 
the cartilage. 



FISTULA IN ANO AND COCCYODYNIA. 169 

While all my operations have been finally successful, I have 
several times seen great suffering and slow healing follow. 

The subjoined cases will illustrate the pain and suffering which 
may follow the operation. 

ILLUSTKATIVE CASES. 

Removal of the Coccyx and Lower Segment of the Sacrum ; Recov- 
ery. — A married lady, twenty- four years of age, w^as thrown from a 
carriage and injured by falling upon her back and side, bruising the 
lower end of the spine, and having what was supposed to be a fract- 
ure of the neck of the femur. After recovering from the imme- 
diate effect of the accident, she suffered from severe pain in the 
coccyx. At first the pain in that region was almost continuous, and 
greatly aggravated by locomotion. For about six months from the 
time of her accident she was tolerably comfortable while resting, but 
suffered greatly when moving around, especially upon rising from a 
chair or sitting down or turning in bed. She also had severe at- 
tacks of sick headache and pains in the back of the neck. 

On physical exploration it was found that the coccyx and lowest 
segment of the sacrum projected inward at nearly right angles to 
the axis of the sacrum. In this dislocation the coccyx was firmly 
fixed. The dislocation and the tenderness gave rise to violent pain 
on defecation. 

The operation consisted in removing the coccyx and the lowest 
segment of the sacrum. A free incision was made and all the mus- 
cles and attached ligaments were separated, and then the part to be 
removed was carefully disarticulated without any injury to the bone. 
The operation was done with all antiseptic precautions, all haemor- 
rhage was controlled, and the edges of the wound were brought to- 
gether with sutures, and dressed with absorbent cotton. 

On recovering from the anaesthetic she complained of the most 
agonizing pain in the lower half of the back, pelvis, and limbs. 
This pain continued for the first three days, and was only partially 
controlled by large hypodermics of Magendie's solution, ten minims, 
every two to four hours. 

An effort was made to relieve the pain with opium given by the 
mouth, but, although seven grains were given in twelve hours, it 
was necessary to repeat the hypodermics to give her relief. During 
all this time of suffering the wound appeared to be healing, there 
was no undue inflammation, and no suppuration. Five days after 
the operation the pain was more easily controlled by the morphine, 
and then the sutures were removed, and the pain from this time on- 



170 DISEASES OF WOMEK 

ward diminislied quite rapidly. At this time tlie wound appeared 
to be completely healed, but a portion of the cicatrix broke down, 
and subsequently healed by granulation. From this time on her 
progress was entirely satisfactory, the pain subsided in the neighbor- 
hood of the wound and spinal column, and she was entirely relieved 
from her sick headaches. 

Removal of Coccyx ; Extreme Pain after Operation ; Delayed Heal- 
ing of the Wound ; Final Recovery. — This was a married lady who 
had one child about eight years old. She had suffered from pelvic 
cellulitis following miscarriage, so that her health was very much 
impaired. She fell down-stairs and injured her coccyx about two 
years before she came under my observation. 

She recovered completely from her pelvic cellulitis. She de- 
veloped all the symptoms and physical signs of coccyodynia. The 
operation was performed in the usual way, and every care taken to 
secure a good result. After ligating the small vessels, which bled 
rather freely, there was a little serous oozing, so, before closing the 
wound with sutures, I introduced a few strands of catgut for drain- 
age, and dressed the wound with berated cotton. 

From the time of the operation she had a great deal of pain and 
tenderness in the region of the wound ; this pain and tenderness in- 
creased until it was necessary to give anodynes liberally to relieve 
them. After about five days the violent pain subsided, but the 
wound was still exceedingly sensitive ; the drainage-threads were re- 
moved about the second day, and the sutures at the end of one week. 
The union was complete, except a sinus in the center which ex- 
tended downward the depth of the original wound. This promptly 
closed up after a few more weeks, but there was still great tender- 
ness remaining there. She returned to her home thirty days after 
the operation, with the wound apparently healed but still tender. 
She was free from her occipital headaches and from most of her dis- 
tressing symptoms. 

Some time after her return home the wound reopened, and, al- 
though every care was taken of the case by the physician in charge, 
it was nearly six months before it healed entirely. Through all this 
time she was free from the suffering which she had before the opera- 
tion, but the wound was still tender. Since then she has been per- 
fectly well. 



CHAPTER IX. 



INFLAIVIMATOEY AFFECTIONS OF THE UTEEUS. 



ANATOMY OF THE UTERUS. 



Before taking up the various forms of endometritis, a few words 
regarding the anatomy and physiology of the uterus will aid in mak- 
ing clear what follows with reference to the pathology and physical 
signs of this variety of uterine disease. The uterus is a triangular 
body with its apex below when in its normal position in the pelvis. 
It varies in size in different persons, and is somewhat larger in those 
who have borne children than in virgins. Its entire length is about 
three inches ; the width from the entrance of one Fallopian tube 
to the other, that 
is, the base of the 
triangle, is about 
two inches ; and it 
is about one inch 
in thickness. It is 
divided into the 
fundus, body, and 
cervix, the cervix 
being about as long 
as the body and 
very nearly as 
thick. The cervix 
is divided into the 
intravaginal and 
the supravaginal 
portions, the form- 
er being that part 
which projects into the vagina, and the latter that which extends 
from above the vagina to the body of the uterus. 




Fig. 



90. — Mold of uterine cavity 
in the virgin (Guyon). 



•i^^,^ 



Fig. 91. — Mold of uter- 
ine cavity in the multi- 
para (Guyon). 




#vi'/f^';'^ -- -r'^!:''&?t ^ 






TcV" 



172 DISEASES OF WOMEN. 

The walls of the uterus are 
composed of three distinct ele- 
ments; the outer co veering being 
peritoneal; the middle coat, un- 
striped muscular Hber; and the 
p:;-:^:- ''-'s^'^'f' internal, mucous membrane. 

y ^' ;■;■;: ' ^^''''^i^.^ The peritonaeum covers the 

~[7;J ','}' uterus only partially, but the mu- 

\ii{pf:/ "^ ;■■■ cous membrane hues the entire 

cavity of the body and cervix, and 
is continuous with the mucouo 
membrane of the vagina, although 
differing decidedly in structure. 
Reference ^vill be again made to 
the relation of the peritonaeum to 
''2,'v the uterus. 

'/'P\' The cavity of the uterus and 

its mucous membrane, which are 
of special interest in this connec- 
tion, are divided into the cervical 
canal and its membrane and the 
cavity of the body and its mem- 
brane. The cavity of the body is 
triangular and curvilinear, while 
the canal of the cervix is spindle- 
shaped. Outlines of the cavity of 
the canal of the uterus differ in 
the parous and imparous uterus 
(Figs. 90 and 91). 

The constricted portion at the 
junction of the bodv and cervix is 
•^7 K' ^ ':,' the OS internum, and the termina- 

yi tion of the canal below is the os 

h ' - ' / externum. Taking the cavity of 

^ /^A_ :' the uterus in its entirety as repre- 

'''f // senting a triangle, with an opening 

'v' ' '' ^ at each of the angles, we tind at 

^1_ A the upper angles the openings of 

'^ ~~r- ~-~~-d' the Fallopian tubes, and at the 

' ., , , ^^ ' '^i ' lower angle the os externum. 

Fig 92 —Section of mucous membrane of r^^^ mUCOUS membrane of the 

uterus fiom near the fundus (Schafer) : . ,• i i t • ia j 

a, epithelium of inner surface ; h, h, Cavity ol the body IS SmOOth and 
utricular glands ; c, connective tissue ; c?, 
muscular tissue. 




VI ~ 



INFLAMMATORY AFFECTIONS OF THE UTERUS. 



173 



thin, the membrane proper not being more than the one twelfth of 
an inch in thickness. It is composed of an ej3ithelial and basement 
layer, and is firmly united to the fibrous tissue of the middle wall 
and connective tissues. It is covered with a single layer of columnar 
epithelium, each epithelial cell having on its free surface a bundle 
of cilia. It contains a number of glands known as the utricular 
glands. In a section of the mucous membrane these glands can be 
seen with a microscope to be lined with ciliated, columnar epithe- 
lium, and to have free openings on the surface of the membrane. 
They dip oblique- 
ly downward, and 
end in the con- 
nective and mus- 
cular tissues im- 
mediately beneath 
the membrane. 

Some of the 
glands are simple- 
others are bifur- 
cated at their low, 
er ends ; some- 
times two of these 
glands have one 
opening on the 
free surface. 

I have said 
that the glands 
dip down into the 
muscular fibers of 
the middle coat ; 
others describe 
the muscular fi- 
bers as running 
up between the 
glands, which 
amounts to the 
same thing. This arrangement of the utricular glands in the mucous 
membrane and the muscular wall of the uterus, with the intervening 
connective tissue, can be seen by referring to Fig. 92. The dilier- 
ences in the infantile and senile uterus can be seen bv reference to 
Figs. 93 and 94. 

The mucous membrane lining the cervical canal is aiTanged in 




Fig. 93. — Transverse section through middle portion of the corpus 
uteri of an infant 7 months old. 



174 



DISEASES OF WOMEN. 



an entirely different manner from that of the cavity of the body. 
From the internal to the external os there are sulci which divide the 




Fig. 94.- 



-Transverse section through the middle portion of the corpus uteri of a woman 
aofed 83. 



membrane into four divisions or columns. The membrane between 
these sulci is arranged in oblique folds or ridges, the whole making 
up that rugous appearance to which the name arhor-vitm has been 
given. Fig. 95 shows this peculiar arrangement of the membrane. 
This membrane is covered throughout with ciliated epithelium. The 
glands of the cervix, known as the glands of ^aboth, are of the 
racemose type ; they open on the free surface, dip down, and divide 
into numerous branches, which extend deep into the connective tis- 
sues. Their openings are found on the surface of the mucous mem- 
brane, both in the elevations and depressions. 

The point at which the mucous membrane of the cervical canal 
unites with the membrane which covers the vaginal portion of the 
cervix is the os uteri externum, and the structure and arrangement 
of the membrane differ on the two sides of this dividing line. That 
within the canal is as I have described it, and that w^hich covers the 
cervix outside of the os internum contains none of the glands of 
Naboth, and has all the general characteristics of the mucous mem- 



INFLAMMATORY AFFECTIONS OF THE UTERUS. 



175 



brane of the vagina. It consists of vascular papillae covered with 
many layers of squamous epithelium. When, as occasionally hap- 
pens, the IS; abothian glands are 
fpund upon the vaginal sur- 
face of the cervix, it is evi- 
dence that they have either 
been developed there or else 
there is eversion of the mu- 
cous membrane of the cervical 
canal, and the latter, I believe, 
is the true explanation of their 
presence in most cases. 

The middle or muscular 
wall of the uterus is composed 
of non-striped muscular iibers 
which appear to be rudiment- 
ary in the un impregnated 
uterus. This middle coat is 
divided into three layers ; a 
thin subperitoneal one which 
is continued outward in the 
location of the uterus, a mid- 
dle layer, and an inner con- 
centrated and very abundant 
layer which surrounds the Fal- 
lopian tubes, OS externum, and 
OS internum ; the inner portion 
of this layer is less dense than 
the rest of it, and there is more 
connective tissue intermingled 
with the iibro - muscular tis- 
sues. It is into this layer that 

the uterine and :N'abothian Fig. 95.— The oblique ramifications of one of the 

median columns m the cervical canal of a 
glands extend. virgin, called the arbor-vitce (9 diameters). 




FUNCTIONS OF THE UTERUS. 

The function of the uterus which is of most interest to the gTue- 
cologist is that of menstruation, which has been discussed in the 
third chapter, to which the reader is referred. It will be spoken 
of again when treating of corporeal endometritis. 

The function of the cervix in relation to gestation and parturition 



176 DISEASES OF WOMEN. 

need not be discussed here ; a few words, however, may be appro- 
priate in regard to the relation of the cervix to impregnation. 

There are two principal theories in reference to the function of 
the cervix uteri in the transmission of the fecundating element to 
the body of the uterus. The one is that the cervix dilates, and 
that the secretion of the glands of Naboth fills the canal and forms a 
medium through which the spermatozoa make their way upward 
by their own migrating power. This appears rational from the fact 
that the secretion of the Xabothian glands is, in its physical proper- 
ties, similar to the seminal fluid. The other theory is, that the cer- 
vix expands, extends, contracts and retracts, producing an action 
of suction, whereby the spermatozoa are carried up into the uterus. 
Whether either or both of these theories is correct, there is no doubt 
that the glands of JSTaboth secrete a fluid that is concerned in the 
great function of reproduction, and that derangement of this func- 
tion tends to the development of cervical endometritis, and that they 
are subject to important pathological changes in that affection. 



METRITIS. 

There are several varieties of metritis. Two of these are desig- 
nated by the character of the inflammation, acute and chronic ; two 
are classed according to the location of the disease, cervical and cor- 
poreal endometritis ; and there are at least three, which are named 
in part from the causes which give rise to them, puerperal, gonor- 
rhoeal, and exanthematous. 

To define these, it may be said that exanthematous metritis occurs 
in the course of some of the eruptive fevers, and usually subsides 
after recovery from the constitutional disease which caused it. It 
is an acute affection, and always tends to recovery, but the uterus 
may be damaged by the disease. When it occurs in the young, as it 
often does, the further development and growth of the uterus may 
be arrested by it. This is, I am sure, the cause of many cases of 
imperfect development of the uterus. The acute disease may sub- 
side, to be followed by a chronic metritis. 

The puerperal metritis is of most interest to the obstetrician, as 
it occurs in connection with parturition. It has a traumatic or sep- 
tic origin, and usually involves the entire uterus, so that changes of 
structure are found in the mucous and muscular coats of the organ. 
This also (when it terminates in recovery) tends to chronic inflam- 
mation of the mucous membrane. The process of involution is ar- 
rested by this inflammation, and when the tissues are changed by 



INFLAMMATORY AFFECTIONS OF THE UTERUS. 177 

inflammatory action the uterus is not only larger than it should be 
but is changed in structure. This will be referred to again under 
the head of subiuvolution. 

Endometritis due to gonorrhoeal virus will also claim a separate 
notice, and with these few observations I shall for the present dis- 
miss all the varieties except acute and chronic endometritis, which 
will be discussed in this chapter. 

Acute Endometritis. — Acute endometritis is exceedingly rare if 
puerperal, gonorrhoeal, and septic inflammations are excluded. I am 
aware that acute cervical or corporeal endometritis is described in 
books, and Thomas claims that the affection occurs frequently. My 
own observations lead me to the conclusion that the acute metritis 
does not progress beyond the stage of acute congestion, and fre- 
quently passes off without causing the slightest permanent change of 
structure. Occasionally the acute stage subsides, and a chronic or 
subacute endometritis foUow^s. When one follows the other in this 
way they stand to each other in the relation of cause and effect. The 
disease may affect the cervix or the body or both at the same time. 

Acute cervical endometritis is more properly an acute congestion, 
which does not cause any very marked disturbance either of the 
pelvic organs or the general system. The symptoms are not pro- 
nounced. Pelvic tenesmus of a slight nature, a sense of aching 
in the pelvic region, with or without backache, is the evidence ob- 
tained at first, and then leucorrhoea soon follows. This discharge is 
usually catarrhal and non -purulent. In some cases there is also a 
vaginitis and a vaginal leucorrhoea which contains some pus-cells, but 
when there is a free purulent discharge there is room for a suspicion 
that the cause may be specific. 

This form of cervical endometritis frequently ends in recovery, 
but may become chronic. All else that needs to be said on this sub- 
ject will be given in the consideration of corporeal endometritis. 

Acute Corporeal Endometritis. — While I have stated that acute 
corporeal endometritis may occur alone, I have always found it ac- 
companied by more or less cervical endometritis. 

The pathology of acute non-specific endometritis I consider to 
be a hypersemia, with such derangement of function as may come 
from it. This congestion may lead to swelling of the mucous mem- 
brane, destruction of its epithelium to some extent, and the forma- 
tion of pus, but these changes are not so marked as they are in me- 
tritis due to specific causes There is derangement of the menstrual 
function ; the flow may be retarded, anticipated, profuse, or scanty. 

A free menstruation is usually very beneficial. Symptoms often 
13 



178 DISEASES OF WOMEN. 

subside as soon as a free flow is established, and if this flow con- 
tinues the usual time or longer the patient promptly recovers. Free 
menstruation has always appeared to me to be a natural means of 
relief in this affection. 

The symptoms and physical signs of general acute endometritis 
are similar to those found in the chronic form of the affection, and 
to save repetition these points will be taken up under the head of 
chronic endometritis. 

Prognosis. — This is favorable. The great majority of cases re- 
cover, and the worst that may happen is that the disease may linger 
and assume the chronic form. 

Causation. — The causes which give rise to ordinary inflammation 
of mucous membranes generally will produce acute endometritis, 
especially if operative at or near the menstrual period. Extreme 
sexual excitation or over-indulgence, exposure to cold, over-fatigue, 
and injuries from careless examinations with the touch or instru- 
ments, are fair examples. 

Treatment. — Complete rest is the first and most important ele- 
ment in the management. To quiet the nervous system, full doses 
of bromide of sodium should be given. This may also relieve pain. 
Should the suffering still persist, opium should be used, but not if it 
can be avoided with justice to the sufferer. 

Hot applications should be made over the hypogastrium. Lin- 
seed-meal poultices, covered with oil-silk, should be preferred, but if 
the patient complains of the weight flannels wrung out of hot water 
may be used in the same manner. The hot-water douche should be 
used twice or three times a day if it gives relief. The bowels should 
be kept free with saline laxatives ; should these cause flatulence and 
pain, a laxative pill of colocynth or rhubarb and belladonna will 
answer better. 

This simple treatment is generally sufficient. More heroic meas- 
ures are often resorted to, but usually with the result of prolonging 
the disease. 

Chronic Endometritis. — One would naturally suppose that in en- 
dometritis the inflammatory process, when once begun at any part 
of the mucous membrane, w^ould extend to the whole endometrium, 
but such is not the case. Clinical observations show that cervical 
endometritis frequently occurs without corporeal. They occur to- 
gether also, but cervical endometritis occurs most frequently. This 
law in the pathology of uterine disease, which appears peculiar, is 
explained possibly by the fact that the mucous membrane in its ana- 
tomical structure, and more especially in its function, differs very 



INFLAMMATORY AFFECTIONS OF THE UTERUS. 179 

widely in the body and cervix uteri. Certain it is that the pathology 
and symptomatology, as well as the physical signs, show that corporeal 
and cervical endometritis are two very distinct affections, demand- 
ing different consideration and treatment. At the same time I must 
admit that they have many features in common, and that they also 
occur together occasionally, hence I shall give some general remarks 
which will apply to both. 

There has been much discussion regarding the pathology of en- 
dometritis, both cervical and corporeal. Much of this difference of 
opinion I think arises from the use of the terms. Some claim that 
the only lesion in this affection is congestion, others claim that 
there is true inflammation ; the difference apparently arising from 
the fact that one defines inflammation as one thing, while another 
believes it to be something else. If endometritis, as we usually 
see it in practice, is compared with the process of acute inflamma- 
tion in other mucous membranes when it runs its entire course, 
then it will be found that endometritis is exceptional. It is known 
that in ordinary inflammation of the mucous membranes there is 
first congestion, then hypersecretion, then suppuration or purulent 
secretion, occasionally ulceration, and rarely, if ever, except in spe- 
cific infiammation, an exudation of plastic lymph ; then recovery 
follows. The damage done to the membranes depends upon whether 
the process ends in suppuration, ulceration, or exudation. If this is 
taken as the typical result of inflammation of mucous membranes, 
then it is a fact that inflammation of the mucous membrane of the 
uterus is extremely rare ; but the fact is, that the process of inflam- 
mation in mucous membranes begins in some cases and progresses 
only to congestion and hypersecretion, and if these are long continued 
certain changes in the mucous glands, epithelium, and cellular tissue 
take place, but suppuration or ulceration does not occur as a rule in 
endometritis. 

The inflammatory process does not begin, run through all its 
stages, and then end, but it begins and progresses to a given stage, 
and is continuous instead of ending at a definite time. 

Cervical Endometritis. — Pathology. — In cervical endometritis, 
whicb is now usually called uterine catarrh, there is very decided 
congestion and hypersecretion of the glands of the cervix. This 
secretion differs very little in its physical properties from that which 
is normal, except that it is excessive in quantity. If this congestion 
is long continued, the exfoliation of epithelium progresses faster than 
its replacement by the development of new cells, so that the membrane 
is covered with young epithelium which gives it a reddish color. 



180 DISEASES OF WOMEN". 

This disturbance of the balance between the process of exfoliation 
and reproduction not only involv^es the mucous membrane of the 
canal, but extends outward from the os externum about half the 
thickness of the walls of the cervix. This gives rise to the con- 
ditions which were described by the older writers as ulceration of 
the cervix uteri. 

As the process advances the mucous membrane becomes thick- 
ened by proliferation of the areolar tissue and by distention of the 
blood-vessels, so that it becomes too large for the surface which 
it covers ; this throws it into the fine rugosities or wrinkles which 
give the surface a granular or papillous appearance. These pro- 
jecting points were supposed by the older pathologists to be an 
enlargement of the papillae of the mucous membrane, but it is 
now known that they are new formations due to areolar hyper- 
plasia. It is supposed, also, that the glands undergo some patho- 
logical change other than mere congestion, but probably the only 
change is a congestion and modification of the epithelium which 
lines them. 

It is claimed by some that new glands are developed upon the 
outer surface of the cervix around the os externum ; I am inclined 
to think, however, that the glands which are seen outside of the os 
externum in cervical endometritis appear there because of the thick- 
ening of the mucous membrane which causes a procidentia or pro- 
lapsus of this membrane. 

It is difficult to believe that the inflammatory process could lead 
to the development of new anatomical structures of a normal char- 
acter, but there is strong evidence to show that this occurs in the 
mucous membrane of the cervix uteri. Sometimes the irregularity 
of surface due to hyperplasia is very marked, especially in cases 
where there is laceration of the cervix. This condition has been 
called " granular degeneration " — a good enough name, if it is re- 
membered that it is produced by a throwing up of the membrane 
into folds or projections by an enlargement and thickening due to 
hyperplasia, and that it is not a degeneration in fact. 

In some cases, especially those that have been treated with caus- 
tics, the mouths of the Nabothian glands become closed and the 
glands become distended by their secretion, and form cyst-like bodies 
deep in the membrane. These are usually seen at the surface as 
whitish, pearly-looking points, which contrast with the deep-red color 
of the mucous membrane around them. To the touch they feel like 
shot, imbedded in the membrane ; these have long been known as 
the '^ ovulae Nabothi " — more recently this condition has been called 



INFLAMMATORY AFFECTIONS OF THE UTERUS. 



181 



" cystic degeneration of the cervix " (Fig. 96). Sometimes one or 
more of them become very large, and bj pressure cause absorption 
of the middle wall of the uterus around them. 

The hjpergemia sometimes extends to the middle coat of the cer- 




Fig. 96. — Section through the mucous membrane of the vaginal portion of the cervix 
showing cystic degeneration. 

vix, and then for a time the tissues are softened and oedematous. 
"With this condition there is usually free leucorrhoea and menor- 
rhagia, especially when the body of the uterus is affected. Occasion- 
ally, though rarely, the menstrual function is suspended or dimin- 
ished. In some cases of long standing, especially when there is 
laceration of the cervix, the areolar hyperplasia extends to all the 
tissues of tlie cervix, giving rise to that induration known as scle- 
rosis. 



182 



DISEASES OF WOMEN. 



These are the principal pathological conditions observed in the 
ordinary forms of cervical endometritis. Occasionally the discharge 




Fig. 98, — H}-pertrophy 
of body of uterus fol- 
lowing corporeal endo- 
metritis (Winckel). 



Fig. 99. — General enlarge- 
ment of uterus, contrasting 
with the two preceding fig- 
ures (Winckel). 



Fig. 97. — Thickening and 
elongation of the cervix, as 
a result of cervical endome- 
tritis (Winckel). 



and 



may be muco - purulent, at times it is 
sero-muco-purulent ; but this occurs only 
in extreme cases, and usually is due to 
hence need not be considered in this con- 



some specinc cause, 
nection. 

The ordinary form of cervical endometritis, described above, 
occurs in parous and im parous alike. There is another form of cer- 
vical endometritis v^hich occurs only in the imparous, and has some 
peculiar characteristics which should be noticed here. In these cases 
the changes in the vessels already noted may or may not be present; 
usually they are not. The discharge from the cervical canal is not 
usually profuse, but it is peculiar in character. In place of the clear, 
translucent secretion we find a very thick and exceedingly tenacious 
material of the consistency of thick glue, and of a darkish color not 
unlike pneumonic sputum, though more solid and dense, and not usu- 
ally so bright-red in color. Associated with this peculiar discharge 



INFLAMMATORY AFFECTIONS OF THE UTERUS. 183 

tliere are iisuallj marked tenderness and djsmenorrhoea, whicli are 
not accounted for by any other condition of the uterus than the state 
of the cervical mucous membrane. I am inclined to think that this 
form of cervical disease is due to some malformation or arrest of de- 
velopment of the glands of the mucous membrane. I have been led 
to believe this because it 0C3urs in those in whom the uterus is im- 
perfectly developed generally, and also the same peculiar secretion is 
observed in some women after the menopause, when the uterus and 
its mucous membrane have undergone final involution. 

In other cases of this class the mucous membrane of the cervix 
becomes prolapsed, causing dilatation and inversion of the lips of 
the external os, so that the cervix appears as if it had sustained 
superiicial, bilateral laceration. In such cases the appearance is such 
as to lead to the belief that the patient has borne children, or had a 
miscarriage ; but I have found it associated with unruptured hymen, 
showing that it could not have come from injuries during parturition. 

Dr. Emmet describes cases of laceration that he has seen follow- 
ing criminal abortion in those who have not borne children. In the 
cases to which I refer the anatomical appearances are the same as he 
describes, but I am satisfied that in those that have come under my 
observation the laceration was apparent, not real. As soon as the 
membrane is reduced to its normal dimensions by exsection of a 
portion of it, and relief of the inflammation by treatment is accom- 
plished, the external os contracts, and the cervix resumes its original 
virgin form, showing that no injury to the muscular coats of the 
uterus has ever occurred. 

Symjotomatology. — Cervical endometritis does not necessarily 
give rise to marked constitutional disturbance ; when it does so the 
symptoms usually appear in the form of general debility, especially 
of the nervous system. The patient may become easily fatigued 
and somewhat changed in disposition, and less inchned to mental 
activity. Sometimes there is considerable mental disturbance, but 
much of all this is usually due to the fact that the patient is annoyed 
by the presence of a more or less profuse leucorrhoea, which gives 
her discomfort, and leads her to suppose that she is suffering from 
a serious affection. The constitutional effects of this local affection 
depend very much upon the sensitiveness of the patient. 

The menstrual function is not necessarily affected. In cases of 
long standing there may be irregular menstruation, and the flow may 
be inclined to diminish, but this is not the rule. 

The character of the leucorrhosal discharge is diagnostic. It is 
dense, thick, opaque, and tenacious, while the vaginal leucorrhoea is 



184 DISEASES OF WOMEN. 

serous, non-tenacious, and usually purulent. If the disease is long 
continued backache comes on, the pain being located in the sacral 
region, which distinguishes it from the lumbar pain characteristic of 
general debility and some of the acute diseases. There is often, 
also, some pelvic tenesmus. All these symptoms are usually very 
much aggravated by muscular exercise; the symptoms alone, how- 
ever, are not sufficient to enable one to make a diagnosis. All that 
can be learned from them is simply that there is some uterine affec- 
tion which, if it does not yield promptly to constitutional treatment, 
demands further investigation in order to settle deiinitely its char- 
acter. 

Physical Sigirs. — These, as obtained by the touch, are usually 
rather unsatisfactory. Upon making pressure upon the cervix there 
is sometimes tenderness, but not always ; in some cases a roughened 
condition of the mucous membrane around the os externum can be 
detected by the touch. JSTot infrequently there is a little relaxation 
of the vagina, and the uterus rests lower in the pelvis. 

Speculum examination affords the best means of ascertaining the 
lesions. We can usually see enough of the mucous membrane within 
the OS externum to determine the presence of the inflammation. 
This is rendered more positive when the redness and erosion of the 
membrane extend outward upon the vaginal surface of the cervix, 
and also when there is eversion of the membrane. There is usually 
a free leucorrhoeal discharge from the cervical canal. Sometimes this 
hypersecretion is the only evidence of the disease present. Passing 
the sound into the cervical canal shows that it is more sensitive than 
in health, and the membrane bleeds more easily on touch than 
it should. It will be seen that the physical signs, as well as the 
symptoms, are not by any means marked in cervical endometritis, 
yet they are sufficient for diagnostic purposes. Whenever the con- 
stitutional disturbance and the local symptoms are severe, it may at 
least be suspected that the membrane of the cavity of the body of 
the uterus is also involved. This will be more fully discussed under 
the head of corporeal endometritis. 

In the form of cervical endometritis referred to, in which the 
secretion of the glands is opaque, dark in color, and exceedingly te- 
nacious, the discharge is not at all times very profuse, but enough 
can be obtained by using a small curette to show its character. This 
in itself will be sufficient to determine the diagnosis. 

Causation. — The predisposing causes of endometritis are imper- 
fections in the general organization, and in the development and 
growth of the sexual organs. Scrofulous and tubercular diatheses 



INFLAMMATORY AFFECTIONS OF THE UTERUS. 185 

incline to chronic inflammation of the mucous membranes generally, 
and the membrane of the uterus is no exception. 

When the uterus is under size or malformed in a slight degree, 
so that menstruation is imperfectly performed, an inflammation of 
its mucous membrane is very likely to come on sooner or later. Sed- 
entary habits and unsuitable clothing, over-fatigue in standing or 
walking, or anything which interrupts the return circulation from 
the pelvis, predispose to this aflPection. So, also, deranged nutrition, 
from insuflicient nutriment or over-taxation, mental or physical, 
which leads to impoverishment of the blood. Frequent child-bearing 
and prolonged lactation also predispose to the same trouble. All these 
causes act to produce derangement of innervation and circulation, 
and so favor the development of inflammation. 

The exciting cause which plays the most important part in endo- 
metritis is imperfect involution after confinement or menstruation. 
The great majority of cases take their origin from this imperfection 
of the menstrual or parturient involution. 

Other exciting causes which may be mentioned are injuries to 
the uterus from displacements, the use of ill-fitting pessaries, injuries 
during confinement, causing puerperal inflammations; abortion, es- 
pecially if produced, intemperate coition, and efforts to prevent con- 
ception, and finally gonorrhoea! virus. This specific cause of endo- 
metritis no doubt produces a form of inflammation which differs 
from the non-specific forms, and hence we will refer to it at another 
time. So far as I know the same causes produce both cervical and 
corporeal endometritis, so that in the present state of our knowledge 
I am not prepared to state any difference in the causes of the two 
affections, if any such exists. I am inclined to think, however, that 
as cervical endometritis is beyond doubt much more common than 
corporeal, it may be inferred that the one tends to the development 
of the other. 

Prognosis, — Of the uncomplicated cases of cervical endometritis 
the great majority yield to the proper treatment. There is in some 
a tendency to a recurrence of the disease, even after recovery has 
apparently been perfect. In those cases of imperfect development 
there is not the same certainty of giving complete relief. 

Treatmento — The constitutional treatment of inflammatory affec- 
tions of the uterus should be based upon the principles of the gen- 
eral management of local inflammations. To correct any defect in 
the general health, to improve menstruation, and to calm any excite- 
ment of the nervous system, comprehends the whole subject. The 
sexual organs being dependent upon the nutritive and nervous sys- 



186 DISEASES OF WOMEN". 

terns for support, general tlierapentic agents can only affect tlie one 
bj action through the other. 

There are a few medicines which act especially upon the sexual 
organs, through the circulatory or nerv^ous systems, such as ergot, 
hydrastis canadensis, and the bromides, but their eifects are not al- 
ways efficient in controlling inflammation. 

Constitutional remedies, as already stated, act upon the uteras 
only so far as they improve general nutrition and innervation. In 
view of these facts, little need be said on this part of the subject ; 
every means which can improve the general health should be em- 
ployed in connection with the local ti-eatment. To save repetition, 
the reader is referred to the section on menstrual derangements, 
third chapter, for details of constitutional derangements which usu- 
ally accompany diseases of the uterus. 

Local Treatment. — Local treatment of the diseases of the uterus 
— the one organ of the sexual system wliich is most amenable to local 
treatment — will be given in the history of cases. Some general re- 
marks, however, on the principal facts in uterine therapeutics may 
be submitted in this connection. That which is said now will apply 
in great part to all forms of metritis. 

Local treatment should be employed with the view of accom- 
plishing two objects : first, to remove the disease, and, second, to 
restore the organ to its normal condition. 

It will at once be inferred that if the first object is attained, the 
second will follow as a natural consequence ; but it may or may not, 
according to the character of the treatment employed. I am satis- 
fied that in times past, and even at present, much of the treatment 
of uterine disease, while it arrests the inflammatory trouble, proves 
so destructive to the normal structure of the organ as to render the 
last condition of the patient worse than the first. 

In the management of uterine diseases one may be guided by 
some of the accepted rules laid down by surgeons for the treatment 
of inflammation generally, viz. : Place the diseased organ at rest ; 
quiet irritation by sedatives, and relieve the congestion by depletion, 
astringents, alteratives, and sedatives. To accomplish these objects, 
it is necessary to employ all the improved means brought forward 
by modern investigation, changing and adapting them so as to meet 
the peculiarities of each case. First, then, rest should be secured by 
having the patient abstain from long-continued standing or walking, 
and from over- excitement of the sexual function. If the uterus is 
displaced, it should be replaced, and sustained in its normal position 
by the support of a well-fitting pessary, if need be. 



INFLAMMATORY AFFECTIONS OF THE UTERUS. 187 

To relieve pain and quiet the irritation a vaginal or rectal sup- 
pository made of extract of belladonna, one eighth to one half grain, 
with cocoa-butter, and used at bed-time, will often give great relief. 
Suppositories of iodoform and of conium are also of service when 
used in the same way. 

I desire to call attention specially to the next agent, namely, deple- 
tion, because I regard it is as a remedy of some value. In making this 
statement I am aware that I encounter much professional prejudice. 
Bloodletting has ceased to be the fashion of the day. The lancet is 
condemned as a " little instrument of mighty mischief." Few of 
the younger members of the profession have ever seen a patient bled. 
Local depletion held its own some time after general venesection 
was to a great extent abandoned, but even this has gradually given 
way to the popular prejudice of the day ; nevertheless, the fact in 
surgical therapeutics remains as true as ever, that the removal of 
blood directly from the vessels of an inflamed or congested organ 
gives some temporary relief. 

Frequent repetition of bloodletting should be avoided, but when 
a case is first seen in which there is marked congestion, the abstrac- 
tion of a little blood by a few punctures around the os externum, or 
the superficial scarification of the mucous membrane in this region 
will pave the way for other applications. 

To practice depletion exclusively and persistently, as some of the 
older gynecologists did, is certainly injurious ; but, as a means to be 
employed in suitable cases, it is worthy of consideration. 

Hot water, used as a vaginal douche, is an antiphlogistic which 
was first popularized in this country by T. A. Emmet. It depletes 
the parts by stimulating the circulation, and is at the same time 
something of a local sedative. It is an exceedingly popular remedy 
at the present time, and is used rather indiscriminately in all diseases 
of the pelvic organs, and with heroic persistency. If properly used 
it gives relief in congestion of the vagina and uterus, and in celluHtis 
when the inflammation is limited to the cellular tissue about the cer- 
vix uteri. It is also of service in the passive congestion which often 
accompanies imperfect involution, but in pelvic peritonitis, salpin- 
gitis, and ovaritis it is often harmful. 

It is also very liable to do harm when used, as it often is, after 
plastic operations about the cervix uteri and perinieum. 

Another means of depletion was introduced by J. Mai'ion-Sims. 
He employed a small vaginal tampon of cotton saturated with glyc- 
erin, which caused free exosmosis f rom the mucous membrane, there- 
by relieving capillary engorgement and oedema. 



188 DISEASES OF WOMEX. 

Position has mucli influence in modifying the circulation in the 
pelvis, and hence patients should avoid the too common habit of sit- 
ting all day in a chair because they suffer when they walk. Short 
periods of walking or riding, followed by rest in the recumbent po- 
sition, should be directed. 

In the treatment of endometritis with the applications of cura- 
tive agents, two very important questions arise : First, what agents 
shall be used, and how shall they be applied. Bearing in mind that 
the uterus should not be injured in its structure, the therapeutist is 
bound to reject all the more powerful and destructive agents, such 
as nitric or chromic acid, caustic potash, and the actual cautery. All 
these have been used, and are now, though less extensively, I trust, 
than formerly, in the treatment of simple chronic endometritis, or 
hypersemia of the mucous membrane of the cavity of the uterus. 

Leaving out of account the value of these potent agents in the 
treatment of malignant diseases of the uterus, I desire to be distinctly 
understood as opposed to their use in the treatment of the benign 
uterine diseases. 

I readily admit that inflammation of a mucous membrane can 
and may have been " cured," as the expression is, by such means. 

The oculist could " cure " a chronic conjunctivitis by destroying 
the membrane with strong caustic, but I fear the eye would be hardly 
presentable afterward, and it would surely fail to perform its func- 
tion. There are those who treat the same affections of the mucous 
membrane of the uterus with these destructive agents, and the results 
which follow can be easily imagined. It may be argued, I am aware, 
that strong caustics are being used less and less by the profession in 
the treatment of uterine disease, and I am glad to believe that such 
is the case. J^itric and chromic acids, and other caustics, are being 
laid aside, but only, I fear, to give place in some cases to new but 
none the less destructive agents. I allude to the galvano-cautery and 
the thermo-cautery. These have become the " fashionable " caustics 
or cauteries of the day, and I trust I most thoroughly appreciate their 
value in the treatment of malignant disease, when the destruction of 
tissue is called for ; but, in the treatment of inflammation, they can 
not fail to work great and micalled-for destruction, like the agents 
used in the past. 

The treatment of the cervical canal is fortunately simpler, being 
more easy to reach, and much more tolerant of irritation. The only 
difficulty in the way of making applications is the presence of a tena- 
cious secretion which fills the canal. This should be removed with 
a small curette before the application is made. 




IJSFLAMMATORY AFFECTIONS OF THE UTERUS. 189 

The method of applying these agents is bj using the pipette 
(Fig. lOOj. Regarding the agents to be used, a long list might be 
given, but it will 
suffice to say that 
the safest and most 

efficient are mild "^ Fig. lOO. — Skene's instillation tube. 

solutions, one or two grains to the ounce, of sulphate of zinc, chlo- 
ride of zinc, nitrate of silver, tannic acid, and bichloride of mer- 
cury ; my own preference for general use is tincture of iodine two 
parts, and carbolic acid one part. 

The frequency with which these local applications should be made 
depends upon the nature of the lesions. In ordinary cervical and 
corporeal endometritis, once every five or six days will answer. This 
gives time for the tissues to fully profit by the application before 
it is repeated. 

I am aware that the practice with some is to make local applica- 
tions every day or every other day, but I know that this constant 
manipulation is irritating, and does more harm than good. 

ILLUSTKATIVE CASES. 

A Typical Case of Uncomplicated Cervical Endometritis. — A lady, 
thirty-two years of age, was married at the age of twenty-one, had 
borne six children, and had nursed all of them. Her health had al- 
ways been very good, and her menstruation regular and natural, 
showing that her general health and organization were excellent. 
She nursed her last child for eighteen months, her menses returning 
when her child was ten months old. From that time she had a slight 
leucorrhoeal discharge which gave her no trouble, and was not re 
garded. Before weaning her child she became quite debilitated, com- 
plaining of occasional dizziness, shortness of breath in active exer- 
cise, considerable backache, constipation, and occasionally impaired 
appetite. Her leucorrhoea about this time increased in amount and 
alarmed her, because she attributed her general ill-feehngs to this 
discharge. This was her condition when she first applied for advice. 
On digital examination the uterus was found to be normal in size 
and position, the external os was larger than normal, and there ap- 
peared to be slight roughening of the membrane immediately around 
the OS. A speculum examination revealed an areola of a deep-red 
color around the os externum, and a profuse leucorrhoeal discharge 
from the cervical canal. The cervix appeared to be a little larger 
than normal, but this increase in size was wholly due to enlargement 
of the cervical mucous membrane, which was decidedly congested, 



190 DISEASES OF WOMEK 

and possibly somewhat thickened. Tlie internal os appeared to be 
normal ; the mncous membrane of the cervix bled when touched 
rather gently with the uterine sound. From the fact that her men- 
strual flow was quite regular and normal, and that the internal os 
was not unduly dilated, nor the body of the uterus enlarged or ten- 
der, the diagnoGis of endometritis limited to the cervix was made 
with positiveness. Her general debility was no doubt due to fre- 
quent child-bearing and lactation, and not wholly to her uterine dis- 
ease, as she had supposed ; in fact, I believe that the cause of the 
endometritis was largely, perhaps entirely, due to her exhausted and 
debilitated condition. 

She was directed to wean her child as promptly as possible, and 
to rest from all her taxing household duties ; to spend some time 
every day in the open air, riding mostly, and to take an abundance 
of good nourishing food. The following prescriptions were given 
to her: A teaspoonful of comp. liquorice-powder at bed-time, to be 
repeated every night, the quantity to be increased or diminished in 
order to keep the bowels regular. Two grains of the pyrophosphate 
of iron were given after meals, well diluted, and a glass of claret. 
Locally, she was directed to use a vaginal douche of borax and warm 
water twice a day. This was continued for about two weeks, when 
it was found that she did not apparently derive very much benefit from 
it, and she was directed to use it only once a day, which seemed to 
answer quite as well, and relieved her from the trouble of using it 
twice a day, which she complained of as a considerable annoyance. 
Locally, the treatment consisted of a careful removal of all secretions 
from the cervical canal with a dull curette. In doing this consider- 
able haemorrhage was produced at first, and it was necessary to wait 
until this had subsided before making any local application, but as 
this only occurred a few times it was soon possible to remove the 
secretions without difficulty, and a preparation of equal parts of 
tincture of iodine and carbolic acid was applied thoroughly to the 
entire canal with the glass pipette (Fig. 100). A few drops of this 
mixture was drawn up into the tube by compressing and releasing 
the bulb. The pipette was carried up to the internal os, and while 
it was being slowly withdrawn pressure was made upon the rubber 
bulb, w^hich gently expelled this mixture and thoroughly applied it 
to the entire mucous membrane. This local treatment was repeated 
every five days during the next two succeeding inter-menstrual pe- 
riods, and the general tonic and sustaining treatment continued, 
varying the chalybeate tonics from time to time. From this time 
onward local applications were made after each menstrual period, 



INFLAMMATGEY AFFECTIONS OF THE UTERUS. 191 

aud again in about two weeks, making two local treatments between 
each menstrual period. Her general condition greatly improved ; 
the cervix diminished in size by a marked contraction of the cali- 
ber of the canal ; the lencorrhoeal discharge almost entirely disap- 
peared, and at the end of live months from the time that the treat- 
ment was first begun she was dismissed quite welL She was di- 
rected, however, to return after the menstrual period for two or 
three months, to ascertain if there was any disposition to a recurrence 
of the cervical endometritis. It was found that she remained well, 
and hence recovery was considered to be complete. 

Cervical Endometritis, with Hyperplasia of the Mucous Membrane, 
— This patient was twenty-eight years of age, rather small and deh- 
cate-looking, but had enjoyed good health up to her last confinement. 
She had been married eight years and had three children, the last 
one being ten months old at the time when I saw her first ; she had 
nursed all her children, the first two for about a year, but the last 
one she weaned when it was eight months old, because she did not 
feel well, and had not sufiicient milk for it. When her baby was 
about four months old she began to suffer from leucorrhoea, back- 
ache, and pelvic tenesmus — the latter symptoms being very much 
aggravated by active exercise. She had also lost considerable flesh, 
was easily fatigued, and somewhat nervous and depressed ; her gen- 
eral nutrition appeared to be fair, and her appetite was good ; her 
bowels were regular, and, although her pulse was not strong, she had 
a good, clear, healthy complexion. Digital examination revealed 
slight relaxation of the vagina, especially of the upper portion ; the 
uterus was rather low in the pelvis, and, while the body was normal 
in size, the cervix was considerably enlarged. 

The cervical canal was dilated, and the lips of the external os 
everted. Around the os, and extending outward to about half the 
thickness of the cervical w^alls, the mucous membrane was quite 
granular and rough to the touch. Through the speculum a very free 
leucorrhoeal discharge from the cervix was observed, and the first 
impression was that there was superficial bilateral laceration of the 
cervix, but on more careful investigation it was found that the mus- 
cular wall of the uterus was very little, if at all, injured, and that 
the enlargement of the os externum and the eversion of its lips were 
due to the enlargement of the mucous membrane. 

The corrugations of the thickened mucous membrane were so 
marked as to give a papillomatous appearance, and the congestion 
was such that the parts bled freely on being touched with a sponge. 
The patient was put upon a systematic course of rest and exercise 



192 DISEASES OF WOMEN. 

simple but nourisliing food, and tlie citrate of iron and quinine as a 
tonic. Locally, she was ordered a vaginal douclie of two quarts of 
water, two drachms of borax, and a half drachm of tannic acid to 
be used twice daily. A number of the more prominent points 
of the mucous membrane, which projected from the os externum, 
were removed with the scissors. A borated tampon was introduced 
and removed on the following day, and two days afterward the iodine 
and carbolic acid mixture was applied to the whole length of the cer- 
vical canal with the pipette. One week afterward that portion of the 
cervical mucous membrane which could be seen was smooth, less re- 
dundant and less vascular ; the canal was still dilated, and the rugosi- 
ties of the mucous membrane were abnormally prominent. The 
more prominent portions of the mucous membrane of the canal were 
touched with a hfty-per-cent solution of chloride of zinc applied 
with a camel's-hair brush. Considerable pain followed this applica- 
tion, and continued until late in the evening. From this onward 
the vaginal douche was employed once a day, borax and water only 
being used, the tannic acid being omitted. The carbolic acid and 
iodine were applied to the canal of the cervix with the pipette, the 
secretion being carefully removed with the curette before the appli- 
cation. This local treatment was employed once a week during the 
inter-menstrual periods for about five months, after that one appli- 
cation after each menstrual period for three months longer. At this 
time her general health had been considerably restored, the canal of 
the cervix had returned to its normal size, the leucorrhoeal discharge 
had entirely disappeared, and the mucous membrane around the os 
externum was perfectly normal. She had no further trouble from 
backache or pelvic tenesmus, and she was dismissed perfectly well, 
locally and generally. 

Cervical Endometritis, Stenosis of the External Os, and Cystic De- 
generation of the Mucous Membrane. — This patient was an English 
lady, thirty-nine years of age. She had two children, the youngest 
one being Rye years old. She had an excellent constitution, and her 
health had always been quite perfect. After her second confinement 
her convalescence was interrupted for a short time by some local 
trouble, the nature of which I could not exactly determine. She 
recovered from this, but afterward suffered from uterine leucorrhoea. 
This gave her Yerj little trouble, and as she hoped that it might dis- 
appear she did not seek medical advice until two years afterward, 
when she called upon a physician, who told her that '' she had ulcer- 
ation of the womb." He treated her for about six months by apply- 
ing nitrate of silver, making the applications with a swab through a 



INFLAMMATORY AFFECTIONS OF THE UTERUS. 193 

cylindrical speculum. This I learned from the patient herself, who 
stated that the doctor told her he was using nitrate of silver. 

The treatment diminished the leucorrhoeal discharge, but she 
began to have backache and pelvic tenesmus, with an occasional 
sharp pain in the region of the uterus. She also had slight djs- 
pareunia. She was told by her physician that the ulceration was cured, 
and that her symptoms would all probably pass away, but after wait- 
ing for six months and finding that they did not she came under 
my observation. Her general health was still fairly good, but the 
local symptoms caused her considerable nervous disturbance, and the 
leucorrhoea had returned, but not so profusely as before. The touch 
revealed an enlargement of the cervix uteri, and around the os there 
was a number of quite hard points, some of them j)rojecting a little 
above the general surface, giving an impression that there was a 
number of shot imbedded in the cervix. The os externum could 
not be very clearly made out by the touch. The entire cervix ap- 
peared to be a little denser than normal, and on speculum exami- 
nation the nmcous membrane seemed to be red in spots, while the 
cysts had a whitish or pearly appearance, some of them showing a 
deep-yellow color. The os externum was somewhat puckered from 
scar tissue, one well-marked scar running from the posterior lip of 
the OS outward and backward. This was lighter in color than the 
general mucous membrane. The os admitted a small uterine probe. 
The canal of the cervix, above the contracted os externum, was found 
to be considerably dilated, and contained quite a large accumulation 
of a thick, tenacious, leucorrhoeal secretion. The cervix was tender 
to the touch, but not extremely so ; the body of the uterus appeared 
to be normal in every way. 

The conditions here found illustrate a very common class of cases 
in which there has been ordinary cervical catarrh, which has been 
treated by the application of a caustic to the vaginal surface of the 
cervix and the lips of the os externum. 

The frequent and long-continued use of nitrate of silver almost 
always produces stricture, scar tissue, occlusion of the Nabothian 
glands, and the formation of cysts. The treatment in this case 
was to first take out a triangular piece of the scar tissue from each 
side of the os externum, which enlarged it sufficiently. The cysts 
were then all carefully torn open, and the contents evacuated by 
pressure ; the secretion in the cervical canal was removed with the 
curette, and an appHcation of the tincture of iodine was made to the 
canal and the vaginal portion of the cervix. A hot-water douche 
was directed to be used twice a day. The patient was examined 
14 



194 DISEASES OF WOMEK 

three days after, when the os externum was observed to be contract- 
ing somewhat as the heahng process was going on. A small tampon 
of cotton was introduced into the os externum, and maintained there 
for twenty-four liours by means of the vaginal tampon. It was then 
reintroduced without the vaginal tampon, and again removed at the 
end of the next twenty-four hours. This tampon, while it pre- 
vented the contraction of the os, interfered at tlie same time with 
the process of healing, so it was given up. At the end of a week 
after the iirst treatment there was found still a number of cysts, 
some of them within the cervical canal. These were all opened and 
the leucorrhoeal secretion removed from the canal with the curette, 
and the mixture of iodine and carbolic acid applied ; and tincture of 
iodine alone applied to the vaginal portion of the cervix. 

These applications were repeated once a week, and the warm- 
water douche continued for four months. During this time all 
the local symptoms disappeared except the leucorrhoeal discharge, 
and this diminished in quantity and became less opaque in character, 
but it did not wholly disappear. 

The size of the external os remained ample, while the canal con- 
tracted very decidedl}^, so that it was almost of its normal caliber. 
The scar tissue became less dense, and all tenderness disappeared. 
After the first four months' treatment the patient was seen for an- 
other three months, just after the menstrual period, when the iodine 
and carbolic acid were applied to the cervical canal, and the iodine 
to the vaginal portion of the cervix. Seven months from the time 
that she first came under my observation she was found to be preg- 
nant, and hence was dismissed as recovered. I subsequently learned 
that she passed safely through her confinement, but 1 have had no 
opportunity of examining her since, although I believe that she re- 
mains quite well, and hence it can be inferred that the cure was 
permanent. 

Cervical Endometritis treated by Caustic, which produced Con- 
traction of the lower two thirds of the Cervical Canal. — This lady 
was twenty-eight years of age, of remarkably strong organization, 
and had always enjoyed good health until the birth of her third 
child. At that time she had some difficulty in her labor, and sus- 
tained a slight laceration of the perineum ; after this she had pelvic 
tenesmus and leucorrhoea. "When she first came under my observa- 
tion she had slight prolapsus of the uterus, with retroversion in the 
first degree ; there was cervical endometritis, indicated by the deep- 
red color of the mucous membrane and free leucorrhoea, but there 
was no other pathological change in the mucous membrane. An 



mFLAMMATORY AFFECTIONS OF THE UTERUS. 195 

application of tannin and glycerin was made to the cervical canal, 
the uterus was replaced, and she was told that it would be necessary 
to restore the perinseum in order to give complete relief. The 
thought of an operation somewhat disturbed her mind, and a friend 
advised her to place herself under the care of her physician, a homre- 
opathist. This she did, and at the second visit he told her that he 
had introduced a pencil of nitrate of silver into the womb, and had 
applied some cotton to keep it there, and desired her to return to 
his oflSce the next day so that he might remove the cotton. On the 
way home she suffered severe pain, and was obliged to go to bed as 
soon as she reached the house. She suffered considerably during 
the night, and the following day sent for the physician, who removed 
the cotton, and told her that she would be all right. She continued, 
however, to have a good deal of pain and pelvic tenesmus, especially 
when she tried to stand or walk. For the next two or three days 
she had a discharge which differed from the former leucorrhoea ; it 
was less tenacious, yellow in color, and at times quite offensive in 
odor. She returned to the physician for further treatment as soon 
as she was able. The discharge became very much less, and finally 
disappeared entirely. She was encouraged to hope that she would 
get well without any further treatment. In this, however, she was 
misled. Her backache and pelvic tenesmus increased in severity, 
especially when standing or walking, and she began to have painful 
menstruation. About a year from the time she had the caustic ap- 
plied she returned to me. I found the displacement about the 
same ; there was no leucorrhoeal discharge whatever, and no external 
evidence of the former endometritis. The os externum was con- 
tracted, and its lips curved inward ; the tissues around the os were 
extremely hard, and to the touch and inspection appeared to be mostly 
scar tissue. 

The cervical canal was contracted in its lower two thirds, so that 
a small uterine sound could be passed vsdth difficulty; there was 
none of the elasticity of the normal canal left, but a hard, almost 
cartilaginous condition existed. The passing of the sound caused 
considerable pain, and some hsemorrhage. The patient was then 
sent to my private hospital, and an effort was made to dilate the 
cervix by the use of graduated sounds. This gave pain, and was 
not effectual. Then the whole length of the contracted portion of 
the cervical canal was incised on the two sides, the incisions being 
made with my hysterotome (Fig. 46) through the scar tissue, and 
the canal was then dilated sufficiently to admit a No. 23 sound; 
a tent made of marine lint and dipped in carbolic acid and glycerin, 



196 DISEASES OF WOMEN". 

one part of the former to three of the latter, was passed up into the 
canal and retained there by a vaginal tampon ; this was left in po- 
sition for twentj-four honrs, when it was removed. A short, hard- 
rubber stem-pessary, which reached beyond the line of contraction, 
but not up to the internal os, was introduced and worn for nearly 
three weeks. During that time it was repeatedly removed and tinct- 
ure of iodine applied to the cervical canal, and a vaginal douche of 
borax and warm water was used. The treatment was continued 
throughout with all antiseptic precautions. After the operation on 
the cervix the uterus was kept in place, first by means of a tampon, 
and subsequently by means of the pessary, which answered the 
purpose while the patient remained in a recumbent position. The 
perinseum was then restored, and the patient dismissed after two 
months of treatment in the institution. . She subsequently returned 
to me once a month, when I passed the uterine sound and applied 
the tincture of iodine, in order to prevent any recurrence of the con- 
traction. Six months from the time that she was operated upon she 
became pregnant, and, although some trouble was anticipated in the 
dilatation of the cervix during her labor, there was none. Prof. 
Charles Jewett attended her in her confinement, and all went well, 
and she has remained free from uterine trouble ever since. 

Cervical Endometritis in an Imparous Woman. — This was a cul- 
tivated lady, with an excellent constitution, who began to menstruate 
at fourteen, while she was a school-girl, and continued to do so nor- 
mally until she had been teaching several years in a high school. 
She taught many hours daily, and being strong and very ener- 
getic she preferred to stand, as a rule, while drilling her class. This 
overtaxation brought on dysmenorrhoea, backache, and leucorrhoea. 
These symptoms were not marked at first, but as she kept on at her 
work they gradually increased. When she was twenty-eight years 
of age she came under my care. She had then been married about 
one year, and although her symptoms had not increased — in fact, 
she had enjoyed better health after being relieved from her arduous 
duties as a teacher — still she had backache and leucorrhoea, especially 
on taking active exercise ; and she was sterile. I found the men- 
strual function perfectly normal, except that she had backache and 
some pelvic tenesmus during the flow, but these were relieved to 
some extent if she kept quiet. Her chief symptom at that time v/as 
a rather free leucorrhoea. A digital examination found the pelvic 
organs well developed. There was no tenderness nor any evidence 
of disease that could be obtained by the touch, except that the os 
externum appeared to be larger than is usually found in the virgin 



INFLAMMATORY AFFECTIONS OF THE UTERUS. 197 

cervix. On speculum examination quite a free leucorrhoeal dis- 
charge was observed, and there was a ring of deep-red color in the 
mucous membrane around the os externum. The cervix was rather 
large in proportion to the body of the uterus, and was of a deeper color 
than normal, and the upper portion of the vagina also was congested. 
The canal of the cervix, including the internal os, was normal in 
size, so that the uterine sound could be passed to the fundus without 
difficulty or causing much pain. As her health was quite good, no 
constitutional treatment was necessary. During the succeeding two 
months six applications of iodine and carbolic acid were made to the 
cervical canal. The next month three applications were made of 
iodine alone, and the next month after that glycerin and tannic acid 
were applied. At the end of that time the leucorrhoeal discharge 
had entirely subsided, the patient suffered much less from backache, 
and had no pain or discomfort at her menstrual periods. She was 
then dismissed, and nothing more was heard of her until four years 
afterward, when she returned to inform me that she was two months 
pregnant. I have not seen her since, but have heard through her 
family that she was delivered of a healthy child after a somewhat 
tedious labor. 

Cervical Endometritis in an Imperfectly Developed TTterns. — This 
lady appeared to be rather frail, but had always enjoyed good health. 
She began to menstruate first at thirteen, and for the first year was 
rather irregular, and always had some pain the first day. The flow 
lasted only from two to three days, and the dysmenorrhoea increased 
somewhat from month to month ; and she began to have backache 
before and after menstruation, with occasional leucorrhoea. When she 
was twenty-foui' years old she was married, but from that time onward 
her dysmenorrhoea increased ; she had almost continuous backache, 
and a good deal of tenesmus, with occasional attacks of frequent 
urination. One year after her marriage she came under my observa- 
tion, and I found the uterus rather below the normal size ; there was 
slight anteflexion of the cervix, but the body of the uterus was in its 
normal position. The uterus was tender to the touch, and there was 
also some hypersesthesia of the vagina. A speculum examination 
revealed a general congestion of the cervix and vagina, the cervix 
being smaller than it ought to be ; the os externum was small, and 
while there was a slight vaginal leucorrhoea there was no discharge 
from the cervix. The canal of the cervix was quite large in propor- 
tion to the size of the external os, and the os internum was so small that 
an ordinary-sized uterine sound was passed with difficulty, and caused 
pain. The canal of the cervix contained a plug of very thick, diu-k- 



198 DISEASES OF WOMEN. 

colored, and very tenacious secretion. This was removed with the 
curette, but with great difficulty, and quite a free haemorrhage oc- 
curred during its removal. After removing this secretion very care- 
fully, and waiting until all haemorrhage had subsided, a mixture of 
carbolic acid, glycerin, and water was carefully applied to the entire 
canal for the purpose of neutralizing any septic material which might 
exist there. A small V-shaped piece was removed from each side 
of the cervix at the os externum, and four very superficial incis- 
ions were made at the os internum. The uterine dilator was then 
introduced, and the os internum and externum dilated imtil a No. 9 
sound could be easily introduced. The patient was kept quiet in bed 
for several days, and as there was no constitutional or local disturbance 
at the end of that time she was allowed to get up and go about again. 
From this time onward for about three months the uterine sound 
was passed once a week to prevent contraction of the cervical canal. 
At the same time the secretion was carefully removed from the ca- 
nal, and carbolic acid and tincture of iodine — one part of the former 
to two of the latter — were thoroughly applied. A vaginal injection 
was ordered of one quart of warm water and forty grains of sulphate 
of zinc, to be used once a day. The effect of this treatment was to 
relieve the dysraenorrhoea, backache, and general feeling of discom- 
fort in the pelvis. 

The leucorrhoeal discharge became more free, somewhat lighter in 
color, and less tenacious. The application of iodine and carbolic acid 
was continued for two months longer, when all treatment was sus- 
pended for three months. At the end of that time she returned, 
and stated that her leucorrhoea remained the same, although other- 
wise she felt tolerably well. In passing the sound the canal of the 
cervix was found to be ample, but the character of the secretion had 
returned to what it was when she first came under my observation. 
I made applications of the tincture of iodine to the cervical canal 
for about two months, without apparently improving the condition; 
I then tried a 10-per-cent solution of chloride of zinc, applying it 
once a week, but without improving the case. I then decided to 
remove a longitudinal strip from each side of the mucous membrane 
of the cervical canal ; this was accomplished by seizing the cervix 
with a tenaculum, and then passing a small-sized Sims's curette 



Fig. 101. — Sims's curette. 

(Fig. 101) up to the internal os, and under strong pressure draw- 
ing it down and cutting out a deep strip of the mucous membrane. 



INFLAMMATORY AFFECTIONS OF THE UTERUS. 199 

This was repeated on the opposite side. The idea of removing the 
two sections rather than removing the entire membrane, as recom- 
mended by Sims, Thomas, and others, was to leave a portion of the 
membrane, which would expand as healing took place, and in that 
waj compensate for the loss of tissue, and thereby prevent the oc- 
currence of stricture of the canal by contraction. During the heal- 
ing process the uterine sound was cautiously passed about every third 
day. This at first caused some hsemorrhage and pain, but soon it 
could be done without trouble of either kind resulting from it. The 
applications of iodine were again begun and continued for about 
two months, six applications in all being made. The final effect 
of this was to control the leucorrhoea, and the little discharge that 
remained became more transparent and less tenacious — more like 
the normal secretion of the Nabothian glands. She was then dis- 
missed apparently well, and she remained so, but continued to be 
sterile. 

I have treated a large number of cases of this class in the same 
way, except that I have not lost time in trying different applications, 
but have removed the sections of the mucous membrane at the out- 
set. Two of my patients have subsequently borne children ; several 
of them have had some contraction of the canal, which had to be 
relieved by dilatation. In quite a number of them the leucorrhoea 
has returned, and while I have been able to keep them comfortable 
by occasional treatment, they have never completely recovered. 

Cervical Endometritis in a Young Girl, with Marked Thickening 
of the Mucous Membrane of the Cervix, Dilatation of the External Os, 
and Eversion of the Mucous Membrane. — This girl was rather small, 
delicate, of marked nervous temperament, and highly cultivated. 
Her circumstances were such that she had been able to obtain an 
excellent education and every advantage and accomplishment that 
she could desire. She was precocious, and began to menstruate 
when she was eleven and a half years old. She had always suffered 
slight pain during her menses, and also had leucorrhoea, which was 
trivial at first. She had suffered much from backache, headache, 
and general debility, but was able to attend to her education until 
she was sixteen years old. Her leucorrhoea at that time became 
quite profuse, and her backache and pelvic tenesmus so severe that 
she was obliged to give up muscular exercise almost altogether. 
During this time she had been treated with tonics, and change of air. 
At the age of eighteen she was placed under the care of a physician 
in Kew York, who said that she had some falling of the womb, and 
treated her by tamponing the vagina with cotton, after the method 



200 DISEASES OF WOMEX. 

of Boseman, who, I believe, calls this method of treatment " column- 
ing the vagina." 

She derived no benefit from this, although it was continued for 
several months. In fact, she became much worse. She was then 
placed under mv care, when she was nineteen years of age ; her 
general condition at that time was one of marked neurasthenia. Her 
extremities were cold and clammv, her pulse was feeble and rapid ; 
her pupils were widely dilated, and, while she was naturally of a 
pleasant and happy disposition, she became apprehensive of trouble,- 
and spent most of her time in thinking and talking about her 
symptoms. Some times she was dull and sleepy, at other times 
wakeful and sleepless ; her appetite was capricious — at times good, 
and at other times poor ; her bowels were constipated ; she was quite 
emotional, and easily affected to tears by either pleasant or unpleasant 
mental impressions. 

The uterus was found in its normal position, its body normal in 
size and shape, and not especially tender ; the ovaries were tender ; 
the cervix was quite enlarged, and to the touch gave the usual phys- 
ical signs of a cervix that has sustained a bilateral laceration super- 
ficially, or suflficient to give rise to ectropion, as it is now called. 

The vagina and vulva were quite relaxed, due, I presume, to the 
long-continued use of the tampon ; at least, I know of no other rea- 
son for this condition, although she was evidently of an amorous 
disposition, and no doubt suffered from physiological congestion of 
the sexual organs. I have no reason to believe that she had ever 
abused herself or been abused, unless this tamponing treatment under 
the circumstances may be caUed abuse. 

The speculum revealed a large cervix, looking quite like that of 
a woman who had borne children. There was well-marked eversion 
which brought into view anteriorly and posteriorly about half an 
inch of the cervical mucous membrane, which was easily recognized 
as such by its rugous arrangement, and the presence of the Na- 
bothian glands, which, though they could not be seen, were proved 
to be present at that point by the secretion which was freely poured 
out on the exposed surface. 

The most careful examination failed to find any injury of the 
muscular walls of the cervix showing that the case was one of ever- 
sion of the cervical raucous membrane. This patient entered my 
private institution, and was treated generally by rest, massage, baths, 
and careful attention on the part of the nurse, with a view to im- 
proving her mental condition by diverting her mind from herself, 
and fully occupying her time with the treatment. The bowels were 



INFLAMMATORY AFFECTIONS OF THE UTERUS. 201 

kept regular with a laxative pill ; sleep was secured by a dose of 
bromide in the afternoon, and another at bed-time when necessary ; 
and one ninetieth of a grain of the hydrobromide of hyoscine was 
given three times a day, with the effect of improving her nervous 
system. A vaginal douche was given once a day, consisting of sixty 
grains of sulphate of zinc to a quart of warm water. This had the 
eifect of overcoming the vaginal relaxation after a time. Three 
weeks after she came nnder my care her general health had improved 
noticeably, and she passed through her menstrual period with less 
pain. I then removed the everted portion of the mucous membrane, 
being careful not to make the exsection entirely circumscribe the 
OS externum. On the sides, where the eversion was less marked, 
portions of the membrane were left untouched. This was done to 
avoid stricture, which I presumed might occur after healing. The 
exsection was made with the scissors, and though there was consid- 
erable hsemorrhage, this was controlled by the application of pledgets 
of cotton dipped in chloride of iron, and kept in place by tampon- 
ing. When the tampon was removed the douche of zinc solution 
was resumed, and once a week thereafter iodine and carbolic acid 
were applied to the cervical canal. As the healing progressed the 
external os contracted, and the caliber of the canal diminished ; the 
leucorrhoeal discharge also subsided, and at the end of three months 
the local trouble had entirely disappeared, and the cervix looked like 
a virgin cervix, except that the os was somewhat larger and oblong 
instead of circular. Her general health greatly improved, and she 
was soon able to take gymnastic exercise and cold baths, and to walk 
and ride in the open air. 

She was dismissed quite well, and has remained so. 



CHAPTEK X. 

CORPOKEAL EXDOltETEITIS. 

The most conflicting views are to be found in the literature of 
medicine regarding the relative frequency of corporeal and cervical 
endometritis. Much of this division of opinion comes, no doubt, 
from imperfect knowledge regarding the diagnosis of corporeal endo- 
metritis. 

The facts appear to be as follows : That corporeal endometritis is 
not so often seen as cervical ; that either may occur alone ; that they 
may occur together ; and that corporeal endometritis alone is most 
rare of all. These facts have been obtained from long- continued 
observation in a very large field, and I feel confident of accuracy in 
the facts, because I have given due attention to the means and 
methods of diagnosis — the only way to arrive at correct conclusions. 

There is another cause of confusion on this subject growing out 
of imperfect methods of investigation, and that is, classing under the 
head of metritis some widely-differing pathological conditions, such, 
for example, as the changes in the tissues following the acute puer- 
peral affections of the uterus. 

It will be seen by what follows that, although the diagnosis of 
metritis is difficult, careful attention to that part of the subject will 
secure a degree of accuracy which has not been heretofore generally 
attained. 

Pathology. — The pathology of corporeal endometritis is doubt- 
less the same in character as that of cervical endometritis, but un- 
fortunately there are not the same opportunities of observing the 
changes which take place in the mucous membrane as in the cervical 
form. On this account post-mortem examinations are the chief 
sources of knowledge of the pathology, and as this disease is never 
fatal an opportunity of examining the uterus only occm-s when pa- 
tients with endometritis die of some other affection, hence the inex- 
act knowledge on this subject. 



CORPOREAL ENDOMETRITIS. 203 

There is also a marked liability to error in post-mortem investi- 
gations of tlie endometrium. In constitutional diseases, which prove 
fatal, there are certain changes in the mucous membrane of the ute- 
rus which resemble those of endometritis, yet they are not exactly 
the same, and do not represent the anatomical lesions of uncompli- 
cated endometritis, and should not be taken for such. 

The facts regarding the pathology of corporeal endometritis which 
appear quite definitely settled are as follows : In some cases there is 
a general congestion and thickening of the entire membrane, the 
lesions of vascularity extending to the glands of the uterus. This 
gives rise to increased nutritive activity on the part of these glands, 
and hypersecretion. I am not at all satisfied, however, that the dis- 
charge from these glands is exactly the same as it is from the cervix. 
I am inclined to think that it is more serous, less tenacious, and more 
frequently contains blood than that from the cervical glands. The 
whole mucous membrane may be denuded of its epithelium, or it 
may be so only in parts ; and, again, the congestion appears to be 
greater in spots, and in these places there is thickening of the mem- 
brane. These thickened red patches are generally found at the 
mouths of the glands. 'Not infrequently there are proliferations of 
the mucous membranes, polypoid in character — a condition which is 
sometimes called " endometritis polyposa." This new product is one 
of the most common results of endometritis of long standing. 

Sometimes the walls of the uterus are found thickened so that 
the whole uterus, as well as its cavity, is enlarged. In other cases 
the walls of the uterus have been found diminished in thickness, 
and changed in structure by fatty degeneration. These changes 
in the walls of the uterus may or may not be due to the endo- 
metritis. 

Corporeal endometritis belongs to that class of inflammations in 
which the process does not pass through its various stages, and then 
end in recovery, with or without permanent changes of structure. 
In this it differs from acute inflammations, which begin and run 
through all their stages, and end in recovery. 

If once well established, the inflammation shows very little tend- 
ency to recover without treatment ; hence it is that the cases are 
often found that begin in early life, and continue up to the meno- 
pause. There is very little tendency in the natural history of these 
affections to become worse or change their character ; they often re- 
main the same, excepting that the constitutional disturbance may 
increase, and the patient fail in general health. 

Bymj^tomatology. — Owing to the fact that the diagnosis of cor- 



204: DISEASES OF WOMEN". 

poreal endometritis is difficult, it is very necessary to give close atten- 
tion to the evidence presented. 

The symptoms of this affection are well marked, and, although 
not diagnostic, they are of great value when taken in connection 
with the physical signs. They naturally arrange themselves into 
two classes — constitutional and local. 

The constitutional symptoms are manifested by the nervous sys- 
tem and digestive organs. There is frequently capricious appetite, 
fiatulencCj and constipation. The derangement of the stomach is 
irregular, often varying in a day, showing that it is a reflex nervous 
disturbance, not unlike that which occurs in gestation. The mam- 
mary glands are often sympathetically affected, becoming enlarged 
and tender, and the areola takes on a darker color. These symp- 
toms, taken in the aggregate, resemble very closely those found in 
spurious pregnancy, excepting that the mental obliquity is absent. 
It will be seen that the symptoms, including the derangement of the 
digestive organs, are all such as might be expected from reflex nerv- 
ous derangement, and such, no doubt, is their explanation. 

I am aware that the symptoms here given have all been said to 
occur in cervical endometritis, but, while there may be some slight 
constitutional disturbance from this affection, it is never so well de- 
fined as in corporeal endometritis. 

Symptoms referable to the general nervous system, which occur 
in this affection, are not diagnostic, yet they are valuable when taken 
in connection with the rest of the history. 

Headache, sleeplessness, mental depression, and pains in the spi- 
nal cord, are often present, but 1 know of no special nerve symptoms 
peculiar to corporeal endometritis. Among the local symptoms the 
most important, by far, is derangement of the menstrual function. 
This I consider the symptom by which the differential diagnosis be- 
tween cervical and corporeal endometritis can be made, and therefore 
it should be borne in mind at all times. 

One would naturally expect that in inflammation of the corporeal 
endometrium the function of the membrane would certainly be de- 
ranged, and such is the fact. The catamenial discharge may be pro- 
fuse, scanty, irregular, and attended with pain, or the function may 
be suppressed altogether ; the rule is, however, that profuse, pro- 
longed, and painful menstruation is present. When either of these 
menstrual derangements occurs, and there is no constitutional or other 
local cause to account for it, we may reasonably infer that the mu- 
cous membrane of the uterus is at fault. 

It may appear strange that opposite conditions, like menorrhagia 



CORPOKEAL ENDOMETRITIS. 205 

and amenorrhoea, should occur in the same affection ; but this is ac- 
counted for by the condition of the mucous membrane in the differ- 
ent stages of the disease. The same peculiarities of behavior are 
noticed in inflammation of other mucous membranes ; for example, 
in bronchitis the membrane at lirst may be unduly dry, and at an- 
other stage of the disease there may be a profuse secretion. In ad- 
dition to these changes, in the menstrual function there usually is 
marked backache, not different in character, but being more severe 
than in cervical affections. There is also more pain in the uterus, 
pelvic tenesmus, vesical and rectal irritation. Leucorrhoea is a 
marked symptom also. The character of the discharge, as already 
noticed, is more serous, less tenacious, and more frequently contains 
a few blood- and pus-corpuscles. When cervical and corporeal endo- 
metritis occur together, the discharge shows the characteristics of 
both affections. 

Physicil Sigiis. — The physical signs of endometritis are the 
same in character as those indicative of inflammation elsewhere. 
There is tenderness detected by the bimanual touch, which usually 
shows that the body of the organ is sensitive. After thoroughly 
cleansing the vagina with a douche, a small tampon of cotton should 
be placed against the cervix and allowed to remain for two or three 
hours. If pus is found on the cotton, it is a valuable sign of cor- 
poreal endometritis. By the use of the sound, four indications of 
the disease can be obtained. First, the abnormal tenderness ; second, 
the enlargement of the uterine cavity, as detected by actual meas- 
urement ; third, dilatation of the os externum ; and, Anally, the 
great vascularity of the membrane, as shown by bleeding on 
touch. 

In using the sound for diagnostic purposes in corporeal endome- 
tritis, much skill and practice are necessary in order to make the ex- 
amination with advantage to the diagnostician and safety to the 
patient. Moreover, care should be taken to make a disinfectant ap- 
plication before using the sound, and to be sure that the sound itself 
is thoroughly aseptic. Many of the difficulties following the use of 
the sound, related in the books, I believe to be due to lack of care 
and attention to these points, thus permitting the carrying of septic 
material into the uterus. 

The density of the uterine tissues is a valuable sign in determin- 
ing the existence of endometritis. As a rule, the body of the uterus 
is less dense than normal, excepting in cases of long standing, in 
which there is sometimes induration or hardening of the uterus. 

Prognosis. — Corporeal endometritis is more difficult to manage 



206 DISEASES OF WOMEN, 

than cervical, and hence this has led many of the writers in the past 
to state that the affection is incurable in many cases. At the present 
time I believe that a more favorable view of the matter may be taken. 
The disease in itself is not dangerous to life, and, when uncompli- 
cated, will usually yield to appropriate treatment. There is a decided 
tendency in many cases for it to return, but even then it can be re- 
lieved by removing the cause. The most obstinate cases, and also 
those that are neglected, recover at the menopause. 

The affection is not in itself self -limited, but is limited by the 
period of functional activity of the uterus. There is a prevailing 
opinion that endometritis, when it continues up to the menopause, 
complicates " the change of life,-' and favors the development of 
malignant disease. The former opinion is true, the latter doubtful. 

The results vary with the different kinds of treatment used. I 
have never seen a case cured by certain methods, which have been 
commended to the exclusion of all others ; for example, hot-water 
douching, and the application of the tincture of iodine to the 
vagina. 

Neither does endometritis yield to treatment so long as there is 
a displacement of the uterus, or a laceration of the cervix ; but, when 
all the conditions necessary to recovery are secured, then endometritis 
will yield to local treatment in the vast majority of cases. 

Causation. — The causes of corporeal endometritis have been re- 
ferred to in discussing cervical endometritis ; hence, to save repe- 
tition, it will suffice to say that there are certain conditions oi the 
general system which predispose to the affection. The strumous 
diathesis, imperfect general nutrition from either gross living and 
sedentary habits, or exhaustion from overtaxation, are the chief pre- 
disposing conditions. 

The direct or exciting causes are complicated labors, miscarriages, 
derangement of menstruation, and sepsis. 

The vast majority of cases of corporeal endometritis, which have 
come under my observation, were clearly due to the causes given 
above. In fact, if those caused by gonorrhoea are excluded, nearly 
all the others can be ascribed to lesions of parturition and derange- 
ment of menstruation, which arrest the post-part um and post-men- 
strual involution. 

Treatment, — The constitutional treatment of inflammatory dis- 
eases of the uterus was briefly referred to while discussing the treat- 
ment of cervical endometritis, so that it is only necessary to repeat 
the general statement, that every means should be employed to re- 
store the general health. The treatment must, as a matter of coursCj 



CORPOREAL ENDOMETRITIS. 207 

be adapted to the nature and degree of the impaired state of the 
general organization in the given case. 

The local treatment, such as the hot-water douche, already de- 
scribed, apph'es in part to cervical endometritis, and therefore need 
not be repeated here. It will suffice to give directions regarding 
topical applications to the corporeal mucous membrane. 

I will first consider the indications for intra-uterine medication, 
the remedies to be used, and the means of employing them. This 
question is still with many an unsettled one, both as regards the 
curability of corporeal endometritis, and the value and safety of 
intra-uterine medication. The literature on the subject of intra- 
uterine treatment is not very definite, hence I shall confine myself 
to a few points, which I regard as fairly well established, and Hkely 
to be of service in the treatment of this disease. 

The important questions which come up for consideration on this 
subject are, first, is it safe and advantageous to make intra-uterine 
applications ? Second, if so, what curative agents shall be employed ; 
and, third, how shall they be applied ? 

Turning to the text-books or the current literature on the sub- 
ject in search of an answer to the first question, I find the greatest 
diversity of opinions. 

The pioneer gynecologists of Europe, such as M. Grendrin, M. 
Jobert de Lamballe, Bennet, and Simpson, rarely, if ever, made ap- 
plications beyond the os internum, believing that endometritis could 
be cured by treating the cervix and the cervical canal. On the other 
hand, we find that Aran, Scanzoni, and Gantillon, and Dr. Henry 
Miller (who, by the way, was the first to employ intra-uterine medi- 
cation in this country), Kammerer, Nott, Peaslee, and many others, 
relied to a very great extent on intra-uterine applications for the 
relief of corporeal endometritis. 

Many more names might be mentioned to show the want of har- 
mony among physicians on this point, but no useful knowledge 
would be gained thereby. All that can be learned from a review of 
the literature is that intra-uterine medication is more extensively 
employed now than formerly. Believing that time tends to drift 
the profession to the side of correct therapeutics, it may be inferred 
that local applications to a part or to the whole of the lining mem- 
brane of the uterine cavity are sometimes necessary, if not indispen- 
sable, in treating endometritis. 

In seeking an answer to the second question, one encountei'S a 
variety of medicinal agents, ranging from the actual cautery to the 
blandest anodynes. 



208 DISEASES OF WOMEN". 

Bearing in mind, however, the second object to be gained, name- 
ly, to restore the oi^gan to health, and leave it uninjni'ed, it is evident 
that all destructive agents should be avoided. 

This has already been stated in discussing the treatment of cer- 
vical endometritis, and all that was then said applies with greater 
force in regard to corporeal endometritis, because that portion of the 
mucous membrane is more delicate in stnictm-e. 

In my own practice I employ either bichloride of mercury, one 
grain to an ounce of water ; tincture of iodine ; tincture of iodine, 
two parts, and carbolic acid, one part ; or suppositories of iodoform 
and cocoa-butter. 

There is so much risk in treating the mucous membrane of the 
cavity of the body of the uterus that there are certain precautions 
which sliould be kept in mind. These may be formulated as fol- 
lows : That intra-uterine applications, excepting to the cervical canal, 
should not be used until other means have been thoroughly tried 
and have failed. The uterus should be in or near its normal posi- 
tion. The cervix uteri should be sufficiently dilated to allow any 
excess of the fluid to escape from the cavity of the body. 

After having carefully freed the cervical canal from the secretion, 
the easiest and most effectual way of making applications is to use 
the glass pipette, already described. 

The solution to be employed is drawn up into the glass tube by 
the rubber bulb ; the instrument is then passed up to the os inter- 
num or to the fundus uteri, if desired, and, as it is withdraw^n, press- 
ure is to be made upon the bulb which forces out the solution and 
brings it in contact with the entire lining of the canal. 

The method generally in use of dipping a probe wrapped with 
cotton into the solution, and passing that up into the canal, is very 
unsatisfactory. The cotton on the probe injures the mucous mem- 
brane, and the solution is deposited about the os externum — very 
httle, if any, getting into the canal. 

The injections by means of a syringe and a reflux catheter, com- 
mended by many, I have tried, but I have abandoned the method 
because it is dangerous and unnecessary. 

It is well to use some bland fluid, such as warm water and salt, 
to test the toleration of the uterus before using the more potential 
agents. A small quantity of the agent used is all that is necessary. 
Six to ten drops is sufficient to cover the surface to be treated, and 
more than that is useless. 

When from long-continued congestion the mucous membrane of 
the cavity of the uterus has become hypertrophied, giving rise to 



CORPOREAL ENDOMETRITIS. 209 

that condition now known as endometritis polyposa, the use of the 
curette gives the most prompt relief. The blunt instrument should 
always be used, because it is perfectly effective and free from dan- 
ger. Dilatation of the cervix with tents, as a preliminary to the use 
of the curette, should be avoided. 'No such dilatation is needed, as 
a rule. When the mucous membrane is hypertrophied, the canal 
of the cervix is usually sufficiently dilated to admit a curette large 
enough to do the work. 

Method of Curetting. — The pathological conditions which demand 
the use of the curette have already been referred to. The instru- 
ment which I use has also been described, and the advantages which 
I consider that it possesses have been clearly pointed out. There is 
still something to be said regarding the method of using it. Dilata- 
tion of the cervical canal sufficient to admit the curette is necessary. 
In many cases the dilatation which accompanies the disease is suffi- 
cient. When more is necessary, it should be made rapidly, under 
the local anaesthesia of cocaine, with Goodell's dilator. In case 
it is necessary to give a general anaesthetic, the cocaine is not 
called for. This method of immediate dilatation is greatly in ad- 
vance of the old way of dilating by sponge or sea-tangle tents, 
which always caused great pain, and sometimes inflammation and 
septic infection. 

The patient is placed in Sims' s position and the cervix caught and 
held with a tenaculum. The curette is then curved so that it will 
pass into the uterus and to one side, and, while the to-and-fro motion 
is being made, the instrument is also moved slowly toward the op- 
posite side. I find that, with my curette, fungosities or decidua 
can be pushed off or detached with the upward as well as with the 
downward or scraping motion. When the anterior wall has been 
thoroughly treated, the instrument is withdrawn into the cervix, 
bent a little in the opposite direction, and turned around so that it 
will face the posterior wall, which is then treated in the same man- 
ner as was the anterior. From a large experience I have come to 
look upon this operation as one of the safest in gynsecology, and very 
satisfactory in its results. Of course, the usual surgical cleanliness 
should be observed, and, if there is decomposing matter in the uterus, 
the cavity should be washed out with an antiseptic solution. 

ILLUSTRATIVE CASES. 

The first case to which I shall refer was a patient thirty-two 
years of age, who had been married ten years, and liad given birth 
to two cliildren. She made a good recovery from her last contine- 
15 



210 DISEASES OF WOMEN. 

ment, and nursed her child for abont six months. Her health then 
began to fail, and the child was weaned. 

Two months after this the menses returned, and at the time were 
quite scanty and only lasted for a day or two. After this she suf- 
fered from backache, pelvic tenesmus, and irritable bladder, with 
free leucorrhoea, at first like an ordinary cervical secretion in char- 
acter. Her general condition also became largely disordered. The 
appetite was capricious ; the bowels constipated, and distended from 
flatulence. She also had occasional attacks of nausea, and at times 
headache ; she became quite nervous, and her sleep was broken. Her 
menstruation became irregular, generally coming on at the end of 
two or three weeks and continuing longer than normal, and was too 
free. "When first examined I found the uterus abnormally large, 
the increase in size being mostly of the body and fundus. Bimanual 
pressure being made upon the body of the uterus gave rise to a dull 
pain. A speculum examination revealed considerable redness around 
the OS externum. The discharge, as seen coming from the canal, 
was dark in color, as if stained and streaked with blood ; around 
this tenacious material there was a little sero-purulent discharge 
noticeable. The sound entered two and a half inches, and could 
be moved about considerably in the cavity of the body, showing 
that the cavity was enlarged. Gently touching the fundus and sides 
of the uterus with the sound gave rise to pain, and the patient com- 
plained of a little nausea and faintness. From the general history 
and the physical signs the diagnosis of inflammation, involving the 
entire mucous membrane of the uterus, was made. 

The subsequent history fully corroborated the diagnosis in every 
respect. At this time the patient's tongue was coated, her appetite 
poor, and she was constipated. A dose of blue mass with a grain 
of ipecac was given at night, followed by a Seidlitz powder in the 
morning ; and after this a bitter tonic of Colombo and wine of 
ipecac before meals, A teaspoonful of Parish's compound syrup 
of phosphates, well diluted, was given after meals. 

The constitutional treatment consisted simply of iron tonics, a lax- 
ative pill, plenty of nourishing food, and a very little exercise. Once a 
week I removed the secretion from the cervix, then applied carbolic 
acid and iodine, and ordered a hot-water douche night and morning. 
The local application caused pain for several hours, and did not ap- 
pear to do any good. At the end of the week I passed a medium-sized 
curette into the uterus, and gently curetted the entire mucous mem- 
brane of the body ; this brought away considerable serum and blood, 
some of which, from its dark color, had evidently been retained for 



CORPOREAL ENDOMETRITIS. 211 

a considerable time. There was also muco-purulent material which 
came away at the same time, but this may have come from the cer- 
vix. On carefully examining all that was removed from the uterus, 
several little masses of fungous material, about the size of the head 
of a large pin, were found, and several shreds that looked like por- 
tions of the epithelial layer of a thickened and softened membrane. 
The curetting seemed to be a failure, so far as obtaining any 
large-sized fungosities which I had been led to suspect existed from 
the frequent and profuse menstruation. Considerable pain was 
caused by the use of the curette, and it lasted for several hoars, but 
finally passed away. The patient also complained of being faint and 
having nausea, and, as she appeared pale after the operation, I have 
no doubt that her suffering was very great, though she was a brave 
lady, and did not complain without cause. There was considerable 
oozing of bloody serum from the uterus for two days after the cu- 
retting. About five days afterward an examination revealed a copi- 
ous discharge of cervical secretion, which was rather dark in color 
and slightly yellow, as if it contained pus. Yery small clots of 
blood were also found entangled in it. The cervix was then freed 
from the secretion, and iodine and carbolic acid again applied. The 
next menstrual flow came on at the proper time and was quite free, 
but it did not last quite as long as usual. Two days after the flow 
had subsided I again used the curette, with the result of bringing 
away some blood and muco-serous material, but no shreds of mem- 
brane nor fungosities. The patient suffered much less this time 
from the treatment. From this onward, once a week, a pencil made 
of cocoa-butter, and as much iodoform as the butter would take up 
(about four grains in all), was passed up into the cavity of the uterus 
as near to the fundus as possible ; carbolic acid and iodine were ap- 
plied to the cervical canal. This treatment seeming effectual, and 
the patient improving, it was repeated once a week for about two 
months ; during this time the uterus diminished in size, the discharge 
also became less, and changed to the character of that usually found 
in cervical endometritis. The menstruation then became regular as 
to time and less profuse, and did not last longer than the usual time. 
The intra-uterine applications were then suspended, except the appli- 
cation of iodine and carbolic acid, which was continued once a week 
to the cervical canal for about two months longer. She had then 
improved so much in her general cimdition, and the uterus appear- 
ing to be normal, except that she still had slight cervical leucorrhcva, 
I unwisely told her that she was quite well, and she did not return 
for any after-treatment for six months. Her leucorrhcea at this time 



212 DISEASES OF WOMEN. 

became again rather troublesome, and she came back for further 
care. I then found that her general condition was entirely satis- 
factory ; her menstrual flow was regular and normal ; the internal os 
had contracted to its natural size ; the uterus measured three inched 
only in its longest diameter, and all that remained of the former 
trouble was a hypersemic state of the cervical mucous membrane, 
with leucorrhoea ; this was treated for about six weeks with one part 
of carbolic acid to three of iodine, and then she was dismissed per- 
fectly well. 

I have been informed that she has given birth to a child since 
she was under my care. 

Chronic Corporeal Endometritis. — The patient was twenty-nine 
years old, and had one child when twenty-three, and a miscarriage 
when twenty-five years of age. Up to the time of her miscarriage 
her health had been very good, but from this time she began to 
suffer. 

The menses, formerly normal, began to be too free, and were 
attended with pain. In fact, from the time of the miscarriage she 
had menorrhagia and dysmenorrhoea, and both became more marked 
as time went on. The pain in the uterus at the time of the menses 
was not acute, but was continuous and aching. It began a day or 
two before the flow and continued until the flow ceased, and some- 
times for several days after. There was some irregularity about the 
recurrence and quantity of the menses, and she observed that when 
the flow was very free the pain was not so severe. At some of the 
menstrual periods the flow would begin and go on for a day and 
then stop for hours, and then come on again quite freely. When 
these interruptions took place there usually were clots passed, which 
evidently came from the uterus, because they were expelled after 
pains which differed from the usual pain in being more acute and 
intermittent. 

The menorrhagia and dysmenorrhoea became gradually worse, 
the pain being greater when the flow was less. She became much 
exhausted at each period, either from pain, loss of blood, or both. 
Throughout the whole course of the affection she had a discharge 
from the uterus which was sero-purulent. 

At times, especially before the menstrual period, there was a cer- 
vical leucorrhoea, but the discharge from the body of the uterus was 
most marked and continuous. It was more yellowish in color, less 
tenacious than cervical leucorrhoea usually is, and oftentimes it was 
tinged with blood and quite offensive in odor. 

There was much backache, pain in the pelvis, and wandering 



COKPOREAL ENDOMETRITIS. 213 

pains in the abdomen. The appetite was capricious ; at times fairly 
good, and at other times very poor. She often had nausea, which 
lasted for a short time. The bowels were constipated, and she was 
greatly tormented with flatulence. Her ultimate nutrition was poor ; 
she had lost flesh, and on her face there were many large blotches. 

The nervous system was very considerably disturbed. Originally 
of a cheerful disposition, she became irritable and emotional. Sleep 
was often broken at night, and she had unpleasant dreams. During 
the day, especially after eating, she became drowsy, but seldom could 
sleep, if she tried to do so. In other words, she was anaemic and 
neurasthenic. 

She suffered at times from a spasmodic cough, due evidently to 
deranged innervation. There was no organic disease of the lungs or 
bronchi. The general treatment was tonic and sedative. Mild lax- 
atives were also given. Locally, the hot-water douche was used, 
and equal parts of iodine and carbolic acid were applied to the cervix. 
This did not give any relief to the local symptoms, and her general 
condition improved very little. The menstrual flow was as free and 
painful as before. 

The curette was used, and some fungous material removed ; after 
this she felt better, and the menstrual flow was more natural. Sub- 
sequently she neglected her treatment, and in a few months all the 
old symptoms returned. 

The curette was used again, and a larger quantity of fungous 
material removed ; after this, one part carbolic acid and two of tinct- 
ure of iodine were applied to the whole cavity of the uterus, once a 
week — three such applications being made during the inter-menstrual 
periods. 

The applications caused pain, which compelled her to rest in bed 
during the day on which they were made. The constitutional treat- 
ment was kept up, and the local applications were continued for a 
period of three months. After this an application was made after 
each menstruation for three months. 

In all, her treatment extended over a period of several months. 
She was then quite well in general health, and her menstruation was 
regular and normal. 

It is now eight years since she recovered her health, and she is 
quite well. 



CHAPTER XI. 



f^EI^"voL^TIO^". 



Subinvolution of tlie Uterus after Parturition. — The great in- 
Ciease in the size of the uterus during gestation, and its rapid reduc- 
tion after deliveiy. are among the most remarkable phenomena in 
the animal ecoDomy. 

The uterus dui'ing nine months increases from about two ounces 
to two pounds in weight during the evolution of gestation, and it is 
reduced bv involution in the short space of two or three weeks. 
This process of involution (bv which the uterus is reduced to its 
original size) is a transformation ai^d absorption of the tissnes. The 
stmctural elements of the uterus, which are no longer needed, un- 
dergo fatty degeneration and absoi-pnon. and are in that way dis- 
posed of. 

The time requii-ed for this involution to take place, aud the 
causes which may interiTipt it. have been clearly pointed out by Dr. 
Alexander Sinclair, of Boston, in vol. iv of the "' Transactions of the 
American Gynecological Society.*' IS 79. Dr. Sinclair gives the re- 
sults of careful measurements of the uterus in one hundred and eight 
cases. These measurements were made from twelve to thirty-six 
days after delivery, the average being sixteen days. In the great 
majority of these cases the uterus had been reduced to its norjnal 
size at the end of three weeks. In one the uterus measured two and 
one half inches on the twelfth day. This shows the wonderful ra- 
pidity with which this involution goes on. 

In all the cases in which the involution was retarded, there were 
present certain morbid states, such as laceration of the perinteum or 
cervix uteri, metritis, or septicaemia. 

These observations of Dr. Sinclaii^'s are of the highest value in 
showing the time required for the process of involution, and also the 
conditions which interrupt, retard, or arrest it. 

Pathology. — In uncomplicated cases there ai-e no inflammatory 



SUBINVOLUTION. 215 

products, nor are there any new tissue formations. The structures 
of the uterus are the same as in the normal state, but developed by 
gestation. In Dr. Snow Beck's case the microscopical appearances 
were like those found in the middle period of utero-gestation. In 
other cases evidences of fatty degeneration have been observed in 
the muscular tissues. 

When the involution has been arrested by puerperal metritis, the 
products of the inflammation are found. According to Dr. N oeg- 
gerath, these products are inflammatory exudations and hyperplasia 
of the cells of the areolar tissue. 

Symptomatology. — I have never observed any symptoms which, 
were specially characteristic of imperfect involution. The history 
of the delivery and subsequent progress usually presents some fact 
which would suggest possible subinvolution. 

There are usually present leucorrhoea and backache, and pelvic 
tenesmus upon standing or walking, but all these symptoms occur in 
other affections. 

Physical Signs. — Digital examination shows that the uterus is 
enlarged and softer than normal. Very often it is low down in the 
pelvis. The vagina also is found to be enlarged and relaxed. The 
rule is that if involution is arrested in the uterus it is also arrested 
in the vagina and in the uterine ligaments. There are many ex- 
ceptions to this rule, however ; as, for example, a laceration of the 
cervix uteri and perinseum will arrest involution of the cervix and 
vagina, while the body of the uterus may return through involution 
to its normal size. 

This can be made out easily by the touch in most cases. The 
sound, used through the speculum, shows the exact size of the uterus, 
and when that abnormal size occurs after confinement, and is not 
otherwise accounted for, it is a reliable sign of subinvolution. The 
cer\dx and vagina are usually of a deep, bluish-red color, and there 
is dilatation of the cervical canal, and usually some eversion of the 
lips of the OS externum. 

Prognosis. — Recovery may be expected under proper care if 
treatment is begun early and can be fully carried out, and there are 
no complications which can not be removed. In case that the tissues 
are damaged by metritis the case may go on to sclerosis, and become 
incurable. When the subinvolution is due to injuries of the cervix, 
the restoration of the injured parts is usually followed by a comple- 
tion of the involution. 

Causation. — Injuries, such as laceration of the cervix and peri- 
naeum, and septic infection causing either cellulitis, h^nphangitis, or 



216 DISEASES OF WOMEN. 

metritis, are the chief causes. Getting up too early after confine- 
ment, and engaging in hard work in the erect position, are also liable 
to arrest this process. All the cases that I have seen were traced to 
some of the above-named causes. 

Treatment. — The management of subinvolution usually falls to 
the obstetrician in case he is on the watch for it. When not com- 
plicated with any well-defined puerperal affection it is apt to pass for 
a time unnoticed, because it does not give rise to suffering until the 
patient is about her duties again. 

When the patient begins to go about after her confinement, and 
there is pelvic tenesmus, backache, and leucorrhoea, imperfect invo- 
lution should be suspected ; and, if the physical signs confirm the 
diagnosis, the patient should be put back to bed, and kept there for 
a time. If the recumbent posture is not sufi&cient to restore the 
uterus to its normal position, artificial support should be used, either 
by pessary or tampon. The hot-water douche should be employed, 
and if there is imperfect involution of the vagina and pelvic floor, 
tannin or sulphate of zinc may be occasionally added to the douche. 

In the past, antiphlogistic measures were employed as the chief 
treatment. Leeches were applied to the cervix, and puncturing and 
scarifying were employed to abstract blood from the uterus. This 
depletion is doubtless beneficial when there is well-marked engorge- 
ment, and the general state of the patient is good — not anaemic, as is 
generally the case with these patients. 

Local bloodletting should not be employed unless there is extreme 
congestion, neither should it be repeated more than once or twice. 
A certain degree of hypersemia is necessary to the process of involu- 
tion, and anaemia will arrest the process. Depletion is only admissi- 
ble in morbid hypersemia. That it is useful in such cases is beyond 
doubt. The value of depletion is seen in those who resume the func- 
tion of menstruation soon after delivery. A profuse menstruation is 
generally followed by improvement. 

I have generally relied upon less depressing measures. While 
taking care of the general health, I have advised rest, the hot douche, 
and tincture of iodine applied to the cervix, cervical canal, and upper 
portion of the vagina. When tliese have failed, I have used elec- 
tricity in the same way as in the treatment of uterine fibroids, but 
not with so strong a current. This agent is one of the most valuable 
that we have. Massage of the uterus will also be found useful. 

In cases of long standing there is usually some injury of the cer- 
vix uteri or the pelvic floor ; when such is the case, the lacerations 
must be repaired before involution will be completed. 



SUBINVOLUTIOIT. 217 

It is almost needless to add that all complicating conditions, sucli 
as endometritis, should have due attention. 

Super involution of the Uterus after Parturition. — This affection 
was lirst described by Sir James Y. Simpson, and illustrated with 
cases which occurred in his practice. 

I presume it must be a very rare condition. I have not seen a 
case about the diagnosis of which I felt sure. Premature atrophy of 
the uterus I have seen, due to destructive disease of the ovaries, re- 
moval of the ovaries, and certain peculiar states in which the meno- 
pause occurred prematurely, but a case not so accounted for has not 
occurred in my practice. I saw a patient once in consultation, six 
months after her confinement, who suffered from pain in the abdo- 
men, which was due apparently to adhesions from an old peritonitis. 
The uterus was very small for one who had borne children, in fact it 
was below the size of a virgin uterus. The menses had been scanty. 
I made a diagnosis of superinvolution, and gave the attending phy- 
sician a brief clinical lecture on the subject. He examined the uterus 
afterward, and confirmed my statement regarding the size of it. 
While I felt sure that the pain present, and for which I was con- 
sulted, was in no way connected with the small uterus, I took occasion 
to say that the patient would remain sterile ; and I also predicted 
an early menopause. To my surprise she gave birth to a healthy 
child, of full size, about one year after I had made the diagnosis. 

Perhaps superinvolution, to a certain extent, may not necessarily 
cause sterility, and my diagnosis may in this case have been correct, 
but I do not believe so. 

Owing to my lack of personal knowledge on this subject, I will 
here give in full the case reported by Sir James Y. Simpson, in his 
work on "Diseases of Women" : 

" The subject of this rare pathological affection began to men- 
struate at the age of thirteen, and the catamenia recurred regularly 
every four weeks till she became pregnant when eighteen years old. 
Utero-gestation went on without any unusual phenomena to the full 
t3rm ; and her parturition was natural but tedious, a male child being 
born after a labor of seventeen hours. Nothing unusual occurred 
during her puerperal convalescence and lactation. But subsequent 
to delivery she never menstruated. She was, however, subject to 
frequent attacks of diarrhoea, which she herself believed to be gener- 
ally most severe at recurring monthly intervals ; and the dejections 
were then sometimes tinged with blood. 

"Two years after accoicchenient she became a patient in the fe- 
male ward of the Royal Infirmary, complaining of the state of amenor- 



218 DISEASES OF WOMEN". 

rhoea, with attendant broken health. She suffered from pain in the 
back and hypogastrium, with a sensation of weight and pressure in 
the pelvic region ; djsuria ; a furred tongue ; and a weak compressi- 
ble pulse, generally beating from 80 to 90 in the minute. She was 
thin, feeble, and angemic in appearance. The mammse were shrunk 
and flat. For some time before admission she had suffered much 
from occasional headaches and giddiness ; frequent nausea and vom- 
iting ; palpitation and occasional rigors. 

" On making a vaginal examination, I found the uterus small and 
mobile. The cervix uteri was much atrophied, and the vaginal por- 
tion of it scarcely made any projection into the canal of the vagina. 
The OS uteri was so much contracted as to admit a surgeon's probe 
with difficulty. It was dilated by a slender bougie being left in for 
two or three days ; and, when the uterine sound was subsequently 
used, the uterine cavity was found to be only one and a half inch 
in length, or about an inch less than normal. 

" A variety of means was employed with the view of benefiting 
the general health of the patient, and of exciting action in the uterine 
system, but with little or no effect. 

" Diarrhoea repeatedly occurred during the three or four weeks 
she remained nnder my care, requiring the free use of opiates for its 
restraint ; and as the uterine symptoms did not at the time seem to 
admit of special attention and treatment, the patient was transferred 
to one of the general wards of the hospital, where she was placed 
under the care of my colleague. Dr. Bennett. 

" During the following month the diarrhoea recurred from time 
to time very severely. At last anasarca in the lower extremities and 
albuminuria supervened ; ascites followed ; and shortly afterward her 
face and arms became oedematous. About a month after these symp- 
toms appeared delirium at last came on, the fasces passed involun- 
tarily, and ultimately she died in a state of prolonged coma. 

" On post-mortem inspection some crude tubercles were found in 
both lungs, especially in the left. The liver was enlarged, and showed 
some fatty transformation. The kidneys presented also some stearoid 
degeneration, and in the right there was in addition a small tubercu- 
lar abscess. The large intestines were very much thickened in their 
parietes, and contracted in their caliber, while their mucous mem- 
brane was ulcerated in various parts. Along the lower end of the 
ileum several large ulcerations were seen running circuraferentially 
around the interior of the bowel. One or two ulcerations were also 
found in the stomach. The uterus was very small, and atrophied in 
its length and breadth, its size being diminished about a third below 



SUBIN VOLUTION. 219 

the natural standard in all its measurements, and its parietes were 
correspondingly thin and reduced. The whole length of the uterine 
cavity from the os to the fundus was not more than one inch and a 
half, while the normal uterus usually measures in this direction two 
inches and a half. When a section was made of the posterior wall 
of the organ, the thickness of its parietes at their deepest or most 
developed point was not above three Hnes, instead of the normal 
measurement of five or six lines. The tissue of the uterus appeared 
dense and fibrous, and the section of it presented the orifices of nu- 
merous small vessels. The ovaries seemed also much atrophied, and 
smaller than natural. Their tissue was dense and fibrous, and pre- 
sented no appearance of Graafian vesicles. There was no inflamma- 
tory deposit on the peritoneal surface of the uterus or its appendages ; 
but some thick pus, or tubercular matter, existed in the distended 
cavity of the right Fallopian tube." 



CHAPTER XII. 

SCLEROSIS OF THE UTEEUS. 

Fifteen years ago I employed this term to designate an affection 
of the "uterus, which up to that time had. been known by a variety of 
names — such as chronic interstitial metritis, hypertrophy, chronic 
inflammatory hypertroj)hy, and areolar hyperplasia. Subsequently 
Gallard used the same term in the same way. 

This affection of the uterus is a change of structure produced by 
a pre-existing inflammation or derangement of nutrition, and may 
be more properly considered as the product of morbid action, rather 
than active disease. The term which I have selected, therefore, 
more clearly indicates the true nature of the affection than the names 
of the affections or processes which produce it, and by which it has 
heretofore been designated. 

Pathology. — This comprises certain changes of stnicture, mostly 
of the middle coat of the uterus, which, as already stated, have been 
caused by preceding morbid processes. 

This change of structure consists in an excess of connective tissue, 
the result of an areolar hyperplasia. This element in the structure 
of the uterine walls rapidly increases, encroaching upon the mus- 
cular element, and more especially upon the blood-vessels in the 
connective tissue. The result is marked increase in the density of 
the tissues, and anseraia from pressure upon the vessels. There is 
frequently an increase in the size of the whole organ, but in some 
cases the uterus is not enlarged. In fact, the uterus may notably 
diminish in size, when the hyperplasia is sufficient to cause atrophy 
of the other tissues of the uterus. 

The histological composition of the tissues differs in different 
cases, and in different stages of the development of the affection. 

In those cases which have their genesis in puerperal metritis 
there is generally at first, in addition to liyperplasia of connective 
tissue, a fatty degeneration of the muscular tissue, which has not 



SCLEROSIS OF THE UTERUS. 221 

been disposed of bv the process of involution. There are, also, in 
some cases, some of the products of the inflammation in the form of 
exudation into the tissues. All these give the uterus its increase in 
size, which to some extent is permanent, although the organ may 
diminish very much in time. 

The hyperplasia of the connective tissue causes atrophy of the 
other tissues, and to that extent the uterus is reduced in size. When 
the sclerosis follows non-puerperal metritis the uterus, which dur- 
ing the stage of inflammatory engorgement was larger than normal, 
may become reduced to, or even below, its normal size. This is 
more likely to occur when the hyperplasia is extensive, and involves 
all the tissues of the uterus and their blood-vessels. 

Sclerosis may be general or local. When due to puerperal or 
chronic metritis, or to deranged nutrition from long- continued con- 
gestion, the whole organ shares in the morbid process. When it is 
due to some injury and inflammation, or deranged nutrition of the 
cervix, the body may remain normal. Circumscribed patches of 
sclerosis in the body or cervix have not been found. 

Finally, this is a permanent affection. When once the changes 
of structure have taken place they remain, to a certain extent at 
least. There is no tendency to complete restoration of the normal 
tissue. There may be a slight diminution of the size of the uterus. 
I am inclined to think that even at the menopause, the period at 
which almost all uterine affections subside, this lingers, and possibly 
remains always. 

I have had an opportunity of observing several cases some time 
after the change of life, and the utenis in all of them was larger than 
it should be. Dr. Noeggerath claimed that sclerosis, or chronic me- 
tritis, as he called it, predisposed to cancer of the nterus. This may 
be so. There is in this affection a change of structure, and, accord- 
ing to the rule in pathology, a consequent lowering of the vitality 
of the part, and a predisposition to further degeneration. 

Symj>tomatology. — The clinical history of this affection differs in 
many points from that of other forms of uterine disease, but there 
are no symptoms that are diagnostic. 

There is more marked constitutional disturbance in the pro- 
nounced cases than is found in the average inflammatory affections. 
This may be due largely to the exhausting effect of the disease which 
preceded the sclerosis — this being quite sufiicient to keep up the 
general ill-health. 

There is derangement of menstruation, usually anienorrho?a. In 
well-marked cases neuralgic pains in the uterus are frequently pres- 



222 DISEASES OF WOMEN. 

ent, which are much worse at the menstrual period. The pain at 
this time often begins before the flow and continues throughout the 
whole period, and sometimes a day or so after. In some cases the 
pain is acute and irregular, in others of a dull, aching character, and 
in a few both varieties of pain coexist. The form of suffering may 
be likened to a very great aggravation of all the disagreeable feelings 
of an ordinary menstruation. 

The clinical history (so far as symptoms are concerned) in the 
inter-menstrual period closely resembles that of corporeal endome- 
tritis. 

Physical Signs. — These are briefly as follows : Anaemia of the 
uterus, indicated by the pale appearance of the cervix, as seen through 
the speculum, and suggested by amenorrhoea ; enlargement and in- 
duration of the uterine walls, as detected by touch and sound ; in- 
creased length of the cavity of the uterus without increase of the 
lateral and antero-posterior diameters ; slight retraction of the lips 
of the OS externum, and the small size of the cervical canal compared 
with the size of the walls of the cervix. 

The hardness of the uterus is a most valuable sign, but one that 
is not easily detected. To the touch, the uterus does not in all cases 
appear to be more dense than the virgin uterus, but where it is en- 
larged it is softer in consistency, except in sclerosis ; hence, when 
there is an increase in size and induration, not due to fibroma, the 
evidence is in favor of sclerosis. 

In the great majority of cases the uterus is more tender than in 
any other affection, except acute metritis, and endometritis with flex- 
ion. The touch excites this sensitiveness, and the passage of the 
sound causes marked pain. 

Prognosis. — Sclerosis being a permanent change of structure, 
recovery with or without treatment is the exception. By reheving 
any complication which may be present, such as displacement, the 
patient may be made sufficiently comfortable to reach the menopause, 
and then recovery may take place. 

Sclerosis of the cervix may be relieved to a great extent, some- 
times completely, by trachelorrhaphy, if the cervix has been lacer- 
ated. 

In case the cervix has not been injured its size can be reduced, 
and the tissues may become softened and the nutrition improved by 
taking out a V-shaped piece on each side, and bringing the parts to- 
gether, as in the operation for laceration. 

Causation. — The causes of this affection, given in the literature 
of medicine, are che same as those of almost all other inflammatory 



SCLEROSIS OF THE UTERUS. 223 

diseases of the uterus. In the cases which have come under my own 
observation, they were either acute metritis following child-bearing, 
or miscarriage or long-continued general endometritis, and injuries 
to the cervix during labor. 

This leads me to believe that these are the only causes of this 
affection. In fact, as sclerosis is the result of a deranged nutrition 
of an inflammatory nature, it follows that the cause must be a pre- 
ceding metritis, partial or general. 

Treatment. — Sclerosis is, of course, a preventable disease in the 
majority of cases. If the inflammatory affections which lead to it 
are carefully managed the structural changes will be avoided, except- 
ing in severe puerperal metritis. 

When once the changes in the tissues which constitute true scle- 
rosis have occurred, it is still a question whether any known treat- 
ment can entirely relieve it. As already stated in the prognosis, 
benefit may be obtained by removing complications, such as lacera- 
tion of the cervix. In the hope of causing absorption of the areolar 
tissue, mercury, iodine, copper, and belladonna have all been em- 
ployed ; and, it is needless to say, that the hot- water douche has also 
been frequently tried. 

Dr. Noeggerath, of New York, recommends amputation of the 
cervix, permitting the stump to heal by granulation instead of cover- 
ing it over with vaginal mucous membrane. This he deems advisa- 
ble, not only in the hope of relieving the sclerosis and to counteract 
the effect of the operation, but also to prevent the development of 
malignant disease. 

So far as my own personal observation goes, I am obliged to say 
that I have not seen much benefit from any such treatment, and have 
come to look upon the disease as an incurable one. 

There is one remedy which promises to be useful, and that is 
electricity ; but I have not had experience enough in its use to enable 
me to speak definitely regarding it. I may say, however, that it 
promises more than anything else that I am familiar with, but more 
extensive observation is necessary to determine its true value. 

HISTOET OF CASES. 

Sclerosis of the Cervix Uteri. — This case is one of the very few 
that I have seen of sclerosis of the cervix, not accompanied with 
laceration. It is possible that the cervix had been lacerated during 
one of the patient's confinements, and that the wound had healed, 
but I could not find any trace of such injury. 

The patient was thirty-one years old, and had borne four chil- 



224 DISEASES OF WOMEK 

dren ; tlie last one three years before the time when this history was 
taken. She did not recover from this coniinement as well as she 
had in previous ones, but I could not get any history of serious 
puerperal disease at that time. 

After the continement her health was poor, and she gave the 
history of some uterine disease. Her menstruation was normal, but 
attended with more pelvic pain than formerly. She had suffered 
from leucorrhoea, but this had gradually diminished. At my tirst ex- 
amination I found the body of the uterus normal, but the cervix was 
much enlai-ged and hard to the touch ; the os was circular and small 
in proportion to the size of the cervix — it was an inch and three 
quarters in diameter. To the touch the cervix appeared to be as 
large as the body of the uterus. There was no other lesion found 
except that there was prolapsus in a slight degree. She was treated 
with the hot douche and applications of tincture of iodine, but 
without effect. I then removed, with the hawkbill scissors, a large 
V-shaped piece from the lateral walls of the cervix, and closed the 
wound with sutures, making an operation like that for bilateral lacer- 
ation. Healing was prompt and complete, and the size of the cer- 
vix — at least, the vaginal portion of it — was much reduced. 

She was better for the operation, and at the end of one year I 
found that the whole cervix was nearly of its normal size, and that 
the tissues were soft and more vascular. The operation had the 
effect of changing the nutrition of the parts, and causing absorption 
of the new tissue. 

In sclerosed tissue due to laceration of the cervix, 1 have fre- 
quently seen such favorable changes after operations. 

ILLUSTEATIVE CASES. 

Sclerosis TTteri, following Puerperal Metritis. — This patient was 
thirty-live years old, had been pregnant five times, and given birth 
to four living children. While pregnant at the seventh month with 
her fourth child she received an injury which caused her to give 
birth to a dead foetus a few days afterward. 

During her fifth pregnancy she received a shock from seeing a 
friend in a convulsion ; labor came on immediately, and she was de- 
livered of a seven months' child. Soon after her confinement she 
complained of x^ain and tenderness in the region of the uterus, fol- 
lowed by fever. These sjTnptoms extended over a period of three 
weeks, and there can be little doubt, from the history given, that 
she had acute puerperal metritis, which left her health permanently 
impaired. Since that time her menses have been irregular, scanty, 



SCLEROSIS OF THE UTERUS. 225 

and attended with pain. At times she has a menstrual molimen, but 
no catamenial flow. During the last year she has menstruated twice, 
the last time three months ago. This is the previous history of the 
case. 

She now suffers from extreme debility and ansemia, which is 
shown by her general appearance ; she also complains of ill-detined 
aching pains throughout the pelvis, and in the sacral region ; occa- 
sionally she has very slight leucorrhoea. Her digestive organs are 
also very much deranged, and her nervous system, from the joint 
action of disease and drugs, is a miserable wreck. 

By physical exploration I find that the uterus is enlarged, being 
three quarters of an inch longer than normal. The body and cervix 
are tender to the touch, and the sound carried into the cavity gives 
extreme pain. The cervix is indurated and smooth, and the os is 
smaller and more circular than is usually found in those who have 
borne children. 

Exploring the cavity with the sound, I find that while the longer 
diameter is considerably increased the antero-posterior and lateral 
diameters are shortened. The uterine walls appear to lie in close 
contiguity, so that it is impossible to turn the sound far in any direc- 
tion. These signs obtained by the probe are of vast importance, for 
they indicate clearly that the enlargement of the uterus is due to an 
actual increase in the walls of the organ, and not a mere expansion 
of its cavity. In other words, the growth is concentric, not eccentric. 

The cervix, as seen through the speculum, is notably pale ; the 
OS is small, with its lips curved inward. This retraction, or drawing 
inward of the os, is confirmatory of the opinion that the walls of the 
cervix are enlarged more than the mucous membrane of the cavity. 
When the raucous membrane of the cervix is swollen, and the walls 
remain normal, the lips are enlarged or pouting. 

Briefly, then, the physical signs indicate that there exists a con- 
dition of unusual hardness and enlargement of the uterine walls, 
while the relative size of the cavity is lessened. The uterus is also 
angemic, as can be seen from a glance at the cervix. 

It should be noted that this patient has amenorrhoea — a condition 
that is much more common in the young than in those who have 
borne children, and is seldom found in connection with enlargement 
of the uterus. 

This form of sclerosis presents many points of resemblance to 
that of general endometritis, but they are essentially difterent. 

Contrasting sclerosis with endometritis gives results as follows : 
The one begins with acute inflammation of the uterus, the other 
IG 



226 DISEASES OF WOMEN. 

does not ; in the one there is amenorrhoea, in the other menorrhagia ; 
in the one the uterine walls are enlarged and the cavity diminished, 
while the reverse of this obtains in the other ; the uterus in the one 
is indurated and angemic, in the other it is relaxed and highly con- 
gested. These are plain outline distinctions, easily recognized, and 
characteristic of almost opposite pathological conditions. 

Treatment and Prognosis of the Case. — After each naenstruation 
an effort was made, either with leeches or puncture, to supplement 
the flow by depletion. This was not successful. It was diflicult to 
extract blood from the angemic tissues, and what was accomplished 
did not even relieve the patient. Blistering the cervix was tried 
with some apparent benefit ; cantharidal collodion was applied, and 
a tampon used to protect the vagina until vesication should take 
place. This was repeated several times at intervals of two weeks, 
and the patient had less pain in the uterus and gained a little, but 
whether from the bhstering or tonics and general supporting treat- 
ment, could not be stated with certainty. Iodine was next tried ; it 
was applied to the canal and vaginal surface of the cervix thoroughly 
twice a week, but she did not seem to improve much. 

xAbout this time some one in England reported good results in 
obstinate uterine affections from vaginal suppositories containing 
mercury. I tried these until slight salivation was produced. Some 
harm, but no beneflt was the result. Finally, I may state that some 
relief was obtained, but not much. She profited from constitutional 
treatment, but not much if any from local medication. Considera- 
ble relief was obtained by wearing a Peaslee's ring-pessary, which 
gave a little support to the uterus, but it caused irritation, and had 
to be removed. 

When she was greatly fatigued, and suffered more pain than 
usual, a cotton tampon gave relief also. 

I lost sight of the patient for a number of years, but recently she 
returned to the city and called to see me about some trouble of her 
digestion. She told me then that she never fully recovered until the 
menopause, which occurred at forty-six. Since that time she had 
been fairly well. 

The uterus, though larger than it should have been at her age, 
was smaller than when under observation, fourteen years before. 

Sclerosis Uteri, resulting from Endometritis and General Congestion. 
- — The patient was twenty-four years old when first seen. She was 
highly refined, and of a well-marked nervous temperament. She 
began to menstruate at the age of fourteen, and had continued so to 
do regularly, but had always had slight pain at the menstrual periods. 



SCLEROSIS OF THE UTERUS. 227 

and was unusuaEy nervous and irritable at sucli times. She was 
married at twentj-two, and soon after began to have backache, leu- 
corrhoea, and more pain than formerly during menstruation, and the 
flow was more free. 

These symptoms gradually increased, and her general health failed 
considerably. Pain in the uterus and general pelvic tenesmus were 
added to her other symptoms, and after suffering for two years in 
this way she came under my care. 

I then found the uterus larger than it should have been, and its 
tissues softer than normal, especially those of the cervix. The canal 
of the cervix was larger than normal, and the whole uterus was 
tender to the touch. Passing the sound caused severe pain. There 
was considerable erosion of the cervix, the os externum was di- 
lated, and the mucous membrane was highly congested. There 
was a free muco-purulent discharge which irritated the vagina and 
vulva. 

The usual local treatment for endometritis was employed, and 
the ordinary means were used to improve her general health. Appli- 
cations of nitrate of silver (which I used at that time, according to 
the advice of my former teachers) caused great pain, and were given 
up for milder means, such as tincture of iodine, and tannin and glyc- 
erin. She improved very slowly, and about ten months after she 
came under my care she went to Europe with her husband, who was 
called there on business. She remained in England for about ^ve 
years, and occasionally was treated by a distinguished physician 
there. 

Excepting various kinds of vaginal injections she had no local 
treatment while in England. Her general health improved very 
much, and she bore her local troubles without complaint. 

Upon her return to this country, I found that her menstrual flow 
had diminished until she had less than before her marriage. There 
was Yerj little leucorrhoea, and less pelvic tenesmus. There was 
quite as severe dysmenorrhcea, and she had intermittent pain in the 
uterus of a neuralgic character. The uterus, taken as a whole, was 
a little smaller, and indurated to the touch ; the canal of the cervix 
and the cavity of the body were decidedly diminished in caliber, and 
still tender to the touch of the uterine sound. The os externum was 
contracted, and its lips in place of being everted as formerly were 
now slightly curved inward. In place of the soft vascular condition 
of the cervix, present when she w^as first examined, it was now 
round, well defined, and rather anaemic in appearance. 

It was only by referring to my notes of the case, taken at the 



228 DISEASES OF WOMEN. 

first examination, that I could fully realize the change which had 
taken place. 

I treated her for a short time in the hope of relieving her dys- 
menorrhoea and uterine pains, but without much benefit ; and, as she 
was able to get along by resting at her menstrual period, she was dis- 
missed with the advice to await the menopause, when in all proba- 
bility she would be relievedo 



CHAPTER XIII. 

MEMBKANOUS DYSMENOERHOEA. 

I SHOULD prefer to call this affection membranous menorrhoea, 
believing that the term would be more appropriate, but as the original 
name has been longer in use, and is familiar to the profession, I shall 
not attempt to change it. 

This is an affection which, although rather rare, commands very 
urgently the attention of the gynecologist, because of the dreadful 
suffering which it gives rise to, and the obstinacy with which it has 
heretofore resisted treatment. There is a marked uniformity about 
this disease. In its pathology and clinical history it varies but little 
in different cases. A number of affections resemble it to a limited 
extent, but it stands out well defined, and is easily detected by the 
experienced diagnostician. 

Pathology. — An exfoliation in mass of the mucous membrane of 
the cavity of the body of the uterus at the menstrual period is the 
chief lesion in this affection. Microscopically, the mass presents all 
the histological elements of the true mucous membrane of the uterus, 
including the utricular glands, unchanged by any new or abnormal 
elements. When it is expelled entire, it represents a complete cast 
of the cavity of the uterus, and is triangular, with an irregular open- 
ing at each of the angles, the one representing the internal os uteri, 
and the others corresponding to the ostia of the Fallopian tubes. 
This membrane is rather ragged on the outer surface, but smooth on 
the inner, and looks exactly as the lining membrane of the uterus 
does when in position. The size is usually about an inch long and 
less than that in width, and is generally somewhat larger than the 
normal proportions of the cavity of the uterus ; but this is not always 
the case. In this respect it is like the decidua of pregnancy ; in 
fact, in general appearance it closely resembles the decidua vera, but 
there is a decided difference in its microscopic elements, sufficient at 
least to distinguish. This similarity of the two membranes has led 



230 DISEASES OF WOMEN". 

to their being called the decidua gravida and the decidua menstru- 
al is, the former being the mucous membrane as seen in abortion at a 
very early stage of gestation, the other the membrane as thrown off 
at menstruation in this morbid form. 

Comparing the changes which the mucous membrane undergoes 
in membranous dysmenorrhoea wdth its changes in normal menstru- 
ation, the difference is as follows : In normal menstruation, if we 
accept the views of Dr. Williams, of London, the whole mucous 
membrane undergoes fatty degeneration, disintegration, and elimina- 
tion ; whereas in membranous dysmenorrhoea the mucous membrane 
becomes separated from the walls of the uterus without being 
changed or disintegrated ; exfoliation and expulsion simply occur. 
The way in which the separation of the mucous membrane takes 
place is not positively known. It is presumed, however, that fatty 
degeneration in the deeper structures of the membrane takes place, 
and thereby it becomes detached from the uterus. It is possible, 
also, that the capillary hsemorrhage, instead of occurring on the free 
surface of the membrane, takes place in the deeper structures, and 
in that way dissects off the membrane. This, however, is hypo- 
thetical, and needs confirmation. Sometimes the membrane is ex- 
pelled in shreds, which suggests that the exfoliation either occurs 
in spots or sections, or else that the membrane is completely sep- 
arated from the uterus, but becomes broken up either during ex- 
pulsion or in handling it afterward. It is much more probable that 
it is completely exfoliated and broken up subsequently than that it 
is separated in circumscribed patches. All these facts lead to the 
conclusion that the affection is a perversion of nutrition and func- 
tion rather than an organic disease, inflammatory or otherv^se, which 
gives rise to this peculiar condition of the mucous membrane at 
menstruation. It is clearly evident that there is nothing pathologi- 
cal in the condition of the mucous membrane itself, but that the 
whole morbid process consists in the separation of the membrane in 
mass, in place of disintegration, which is the normal character of 
the mucous membrane in menstruation. There are other views 
regarding the pathology of this affection : one, that it is the result 
of gestation, which is arrested at a very early stage, and that the 
membrane thrown off is really a decidua vera. That this theory is 
fallacious will be seen when the physical signs of this affection are 
discussed. 

The idea that it is an inflammatory affection is not well sustained. 
Ko such product or result of inflammation is found elsewhere in the 
mucous membranes of the body, nor is it necessary that inflammation 



MEMBRANOUS DYSMENORRH(£A. 231 

of any part of the uterus should be present in order to produce 
membranous dysmenorrhoea. 

Associated with this membranous dysmenorrhoea we occasionally 
find inflammatory conditions, but not of the mucous membrane of 
the cavity of the body. There may be, and often is, a general hy- 
peraemia of the uterus and vagina, but usually it is not greater than 
that which is seen in normal menstruation. 

There is occasionally, in cases of long standing, cervical endome- 
tritis, but this does not extend to the body of the uterus. In fact, I 
believe that a well-deiined endometritis can not occur at the same 
time as membranous dysmenorrhoea. This affection, then, is cer- 
tainly sui generis^ and is not the result of inflammation in any form 
or in any stage of the inflammatory process ; neither is it a utero-ges- 
tation ending in abortion at a very early stage of pregnancy, as some 
have maintained ; neither does the membrane partake of the nature 
of any of the morbid neoplasms which occur in mucous membranes 
elsewhere in the body. 

The mucoas membrane in this affection is developed in the nat- 
ural manner after each menstruation, and the gross appearances and 
histological composition of this structure show that it is normal, and 
differs in no way from the mucous membrane of the uterus up to 
the time when the menstrual flow is about to begin. Perhaps there 
is, in some cases, an increase in the quantity of the membrane, but 
only to a very limited extent, if at all. In short, the only pathol- 
ogy connected with this affection is in the manner in which the 
membrane is thrown off. 

Symptomatology. — This affection occurs in single and married 
women — about as often in one class as the other, perhaps. It also 
occurs in those who have borne children, but in most of the cases 
that I have seen in married women the patients have been sterile. 
The recurrence of the menstruation is generally regular ; sometimes 
it is delayed, and sometimes there is a sense of pelvic discomfort 
before the menstrual flow, but not always. The chief symptom is 
the pain which comes on usually during the first day, sometimes 
later, and increases in severity, and is somewhat intermittent in 
character until the membrane is expelled, wdien it rather abruptly 
subsides. 

The flow sometimes is scanty previous to the expulsion of the 
membrane, and after that it is generally quite free ; at times abnor- 
mally so, and occasionally small clots are passed. 

Sometimes there is a leucorrhoeal discharge succeeding the men- 
strual flow, the discharge being occasionally tinged with bloiui. In 



232 



DISEASES OF WOMEIT. 



other cases the menstrual How subsides after the expulsion of the 
membrane, and no leucorrhoea of any account occurs afterward. 

There is really nothing in the clinical history of this affection by 
which it can be positively distinguished from dysmenorrhoea due to 




Fig. 102, — The two sides of a half-membrane from a multipara; from the cavity of the 
body. The slight puckering present is due to alcohol. 

other causes. Hence the diagnosis must always depend upon the 
physical signs. 

Physical Signs. — In order to make a diagnosis, it is absolutely 

necessary that the membrane expelled 
should be preserved and examined. 
The gross appearances of the speci- 
men are usually all that is necessary 
to satisfy the diagnostician regard- 
ing the nature of the affection, but 
in cases where there is a doubt the 
microscope must be called in to aid 
in the diagnosis. 

The morbid materials expelled 
from the uterus which simulate the 
membrane produced in this affection 
are the decidua expelled in abortion 
in the earliest stages of pregnancy ; 
the masses of fibrin which have 
formed in the uterus in menorrhagia ; very dense masses of secre- 
tion from the cervix ; and the membranous-looking shreds expelled 
from the cervix and vagina after astringent or caustic applications. 




Fig. 103. — Half a membrane from a 
virgin; from the body of the 
uterus only. 



MEMBRANOUS DYSMENORRHCEA. 



233 



■ 


IP 


HI 


lE^ 






1 


Bfl 


1' jO^HI 




Fig. 104 a. — Frag- 
ments of mem- 
brane in the con- 
dition in which 
they are often 
expelled. 



The decidua in early abortion is most difficult to distinguish 
from the menstrual membrane. In the early abortion the mem- 
brane expelled is usually 
larger and more ovoid or 
round, and not so mark- 
edly triangular as the 
decidua of menstruation, 
and is also thicker, and 
usually is accompanied 
with villi of the cho- 
rion. If there is still 
a doubt, the microscope 
reveals the fact that the 
menstrual membrane pos- 
sesses only small cells, 
while those of the de- 
cidua-vera membrane are so great as to 
be easily distinguished. There is a de- 
cided microscopic difference in the epi- 
thelium, the tubes, and the inter-glandular 
tissue. This difference between the two 
membranes is not only in the decidua of 
early abortion, but also in the decidua of 
extra-uterine pregnancy. In being thus able to distinguish be- 
tween the decidua of pregnancy and the membrane of menstrua- 
tion, the only great difficulty in 
the diagnosis is overcome. 

Inspection will enable one to dis- 
tinguish shreds of fibrin, masses of 
unusually dense secretion of the cer- 
vix, and shreds from the cervix 
and the vagina after astringent ap- 
plications from the menstrual mem- 
brane. 

The diagnosis can be made with 
great certainty. 

Causation. — Discarding the cur- 
rent views regarding membranous 
dysmenorrhoea — that is, that it is 
due to inflammation, or else the re- 
sult of gestation — one is left with 
out any very rational view to offer 



Fig. 104. — A cast from a 
virgin, where the cervix 
is also involved. 




Figs. 104 b and 104 c. — A cast which 
might be mistaken for a product 
of conception : /;/, shaggy interior ; 
cS, film of membrane covering it ; 
f, filaments from cervix. 



234 DISEASES OF WOMEN. 

regarding its causation. While it is not, perhaps, the part of wisdom 
to discredit the accepted views on any question in medicine until one 
has something more reliable to offer, still, if the causes assigned can 
be readily shown to be incorrect, it is infinitely better and safer to 
be entirely in ignorance of the causes of things than to attribute 
them to the wrong causes. Fortunately, however, while I find my- 
self at variance with most of the recent authorities regarding the 
cause of this affection, I am in perfect harmony with the views of 
Dr. Oldham, who was the first to discover " dysmenorrhoea mem- 
branacea." 

Dr. Oldham distinctly pointed out the characteristics of this affec- 
tion, and stated that the membrane is formed under abnormal ovarian 
stimulus ; and I am fully satisfied that he was not only the discoverer 
of the disease, but also conceived the true idea regarding the cause of 
it — viz., some undue ovarian influence or sexual excitation. In other 
words, it would appear to be some derangement of innervation and 
nutrition. 

Taking this view of the causation, I expect to find myself in har- 
mony with the neurologists at least. This class of specialists mani- 
fests a wilHngness to trace many diseases originally to some derange- 
ment of the nervous system, when they find anything like good 
reasons for so doing. Hence, I expect their support in choosing, as 
I do, to believe that the starting-point in the pathology of this affec- 
tion must be some derangement of innervation produced by disease 
or functional disturbance of the ovaries. Confirmation of this view 
regarding the cause of membranous dysmenorrhoea may be found in 
studying the agencies which give rise to other morbid states of the 
uterus, like the fibroid growth, for example, which in its anatomical 
elements does not differ especially from the tissues of the uterus 
from which it springs ; and, if we could find the cause of this devi- 
ation from healthy nutrition, it might be applicable to the disease 
under discussion. But, unfortunately, the causes of fibroid tumors 
given in our literature are unsatisfactory, and by no means well sus- 
tained. 

From the fact that uterine fibroids are more common in sterile 
women than in others, it would appear that sterility predisposes to 
their development, and perhaps no better explanation of the cause of 
these growths has ever been given than that of my somewhat hu- 
morous friend, who said that "the uterus, being prepared for normal 
work and not finding it to do, took up the development of fibroids 
as a sort of occupation for its formative powers." May it not, then, 
be that a well-defined predisposition to reproduction, uncalled for by 



MEMBRANOUS DYSMENORRHCEA. 235 

gestation, excites this morbid action on the part of the uterus which 
leads to this abnormal exfoliation of its mucous membraue ? This 
view might at least be entertained, because in other cases, when we 
are unable to detect the cause of a disease in something that is tan- 
gible, we usually attribute it to deranged innervation and conse- 
quent malnutrition. This view of the causation is, to some extent, 
sustained by the effect of medicines upon the lesions. This affec- 
tion has always been recognized as one that is often difficult to cure, 
many times incurable, in the hands of the most competent phy- 
sicians and surgeons. This possibly may have been due to misap- 
prehension of the nature and cause of the disease, and hence falla- 
cious therapeutics, rather than to the incurable character of the 
disease. 

In favor of this line of thought I may state that the patients 
whom I have treated in years past, on the theory that the cause 
was inflammatory, have derived little benefit, while those who were 
treated for deranged innervation, malnutrition, and undue ovarian 
excitation, have made very much better progress. I am inclined to 
attribute most of the trouble to ovarian influence, the condition of 
the ovaries being that of an undue nerve excitation and possible 
congestion. I have been led to this belief by two facts : that the 
majority of the patients that I have seen have been subjects of a 
highly nervous organization, and in most of them there has been 
tenderness of the ovaries, and pain at times, without there being any 
evidence of ovaritis. 

The rheumatic diathesis is said to favor this affection, and it is 
possible that this may be so, although I am unable to recall any of 
my patients as being rheumatic ; neither have I been able to trace 
it to the tubercular or strumous diathesis, nor to syphilis. It is 
certain, however, that, if either of these conditions existed, it would 
have its influence in helping to keep up the uterine trouble, and 
every effort should therefore be made to relieve it by treatment. 

Treatment. — The treatment of this affection is necessarily both 
palliative and curative. While the patient is suffering during the 
expulsion of the membrane, it is very necessary to relieve the pain 
as far as possible. This, of course, can be most promptly done by 
the use of opium, which should be avoided if possible, however, be- 
cause of its after-effects, Sodium salicylate and antipyrine, Ave 
grains each, may be given when the stomach is empty. 

Chloral hydrate answers fairly well in some cases. I am not 
sure that it has any advantages over chloroform, camphor, and 
belladonna, or conium and cannabis Indica ; in fact, in the major- 



236 DISEASES OF WOMEN. 

itj of cases one has an opportunity to try several agents, and, of 
course, the patient will decide which gives most relief. Indications 
for general treatment are to quiet all nervous disturbance and to 
improve the general nutrition of the mucous membrane. It so 
happens that when the first part is attended to the latter will follow 
in due order. 

To quiet the nervous irritation and disturbance there is nothing 
that equals the bromide of sodium. This should be given in twenty- 
or thirty-grain doses three times a day for ten days or two weeks 
before the menstrual period. And, if the pain is not severe enough 
to require the addition of some of the remedies already named to re- 
lieve it, the bromide may be continued throughout the menstrual 
period and several days after. From this it would appear that the 
bromide is to be used continuously ; but one or two weeks in each 
month it can be omitted. When the bromide has been employed 
for some time, and it seems desirable to give it up, conium may be 
administered in moderate doses combined with camphor, if the pa- 
tient is weak. If there is any evidence of the rheumatic diathesis, 
the bromide of lithium should be given. Next to quieting the nerv- 
ous system, any debihty that may exist should be overcome by nerve 
tonics. Undue nervous excitation so often goes hand in hand with 
nervous depression that in many cases it is necessary to combine the 
tonic and sedative treatment. All the remedies which may be used 
need not be here mentioned. In regard to the modification of nu- 
trition, it need only be said that any accompanying derangements of 
the digestive organs that may be found should receive careful atten- 
tion ; but this hardly need be mentioned in this connection. 

My rule of treatment has been, after subduing all nervous dis- 
turbances, to put the patient upon the iodide of sodium in case she 
is in fair strength and inclined to flesh. If there is ansemia, I prefer 
the iodide of iron. If these do not accomplish the object, I employ 
mercury, giving it in small doses, never continuing it long enough 
to produce salivation, carefully watching to avoid this. In cases of 
anaemia, where I have feared the debilitating effect of this alterative, 
I have given the bichloride of mercury with iron. After keeping 
them upon this treatment until I could see some evidence of its 
effects, I have then put them upon iodine and arsenic. 

In regard to local treatment, I have been entirely guided by the 
views of the pathology as expressed above, and have therefore em- 
ployed alteratives and sedatives almost exclusively. Of these I have 
found iodoform most effectual. I have also used iodine and mer-^ 
cury with advantage. In cases where I have found any complications 



MEMBRANOUS DYSMENORRHCEA. 237 

I have carefully attended to them, restoring displacements and cor- 
recting Hexions, and so on. When the canal of the cervix has been 
at all constricted I have enlarged it by incision and dilatation. 

When the congestion which occurs at the menstrual period has 
not subsided in a few days, I have employed the warm-water douche. 
After this, I have applied to the cavity of the uterus small bougies 
of cocoa-butter with as much iodoform as they would take up. Three 
or four grains of iodoform mixed with vaseline that has been lique- 
fied by heat, and introduced through the pipette, is perhaps the best 
method of applying it. This has been introduced once a week or 
once every five days. When there has been much tenderness, and 
the use of the pencils has caused pain, I formerly used aconite and 
opium and iodine ; this I have introduced into the cavity of the 
uterus. I am now trying cocaine to subdue the tenderness as a pre- 
paratory means to the use of the iodoform. Eut so far this new 
remedy has not been a perfect success. 

In cases where this has failed and the uterus was not especially 
sensitive to intra-uterine medication, I have instilled into the uterine 
cavity a few drops of a 5-per-cent solution of carbolic acid, making 
one application a few days after the menstrual fiow and not repeat- 
ing it until the next period. In the interval I have used the iodo- 
form. I have also used the fluid extract of conium and hydrastis 
Canadensis ; but this I have found gives more pain than any of the 
other applications that I have used ; and so of late I have used an 
infusion of the hydrastis alone, which appears to answer as well and 
gives less pain. 

HISTORY OF CASES. 

Case I. Membranous Dysmenorrhoea m a Married Lady who was 
never Pregnant. — This patient was forty-one years of age, of good 
constitution, and had been married eight years. She began to men- 
struate at thirteen, and continued to do so regularly and normally 
until she was twenty-one ; then she began to have occasional pain, 
about the menstrual period, in the region of the ovaries. About a 
year after this she began to have severe uterine pains during the 
menses, and states that she occasionally passed masses that looked 
like membrane from the uterus ; they were small, however, and did 
not appear at each period. 

After her marriage the pain at the menstrual periods became 
worse, and almost every month she passed a membranous cast of the 
uterus. The usual history of each menstruation is that the flow be- 
gins not very free, and, after continuing for about five hours, the 
pain becomes very intense and lasts from three to eight hours, when 



238 DISEASES OF WOMEN. 

she expels the membrane and the pain subsides, the flow continuing 
for a day or a day and a half after the membrane has been expelled. 

The flow, taken altogether, is not profuse, and only lasts from 
two to two and a half days, while formerly — that is, before her dys- 
menorrhoea began — it used to continue from four to five days. When 
first seen, her general health was good, but she was rather hysterical 
and nervous, and was somewhat depressed and disappointed because 
she had not had children. 

She described the suffering at her menstrual periods as some- 
thing unbearable, although it did not last more than a few hours at 
a time. She was first examined midway between the menstrual 
periods. The uterus was then found to be normal in size and in 
good position. The internal os was rather sensitive and appeared 
to be slightly contracted ; there was also a distended IN^abothian 
gland in the middle third of the cervical canal, but the uterus pre- 
sented a normal appearance in every other respect. There was no 
congestion ; in fact, at this time the mucous membrane appeared 
rather anaemic. 

The diagnosis was left an open question until the next menstrual 
period, when I obtained the membrane expelled and had it examined 
by my friend Professor Frank Ferguson. His report stated that the 
specimen was uterine mucous membrane unchanged in its histological 
composition. This settled the question of diagnosis. 

Careful inquiry elicited the fact that she had never been preg- 
nant, so far as I could rely upon her testimony, which I believe to 
be accurate because of her great desire to have children. I also 
learned that on several occasions she had lived apart from her hus- 
band, who was of necessity absent on business for several months at 
a time, and that she suffered just the same, and at each month there 
was an expulsion of membrane, showing conclusively that there was 
no possibility of mistaking this affection for pregnancy and abortion. 

The treatment consisted, first, in placing her upon the following 
mixture : Half a grain of the bichloride of mercury, one drachm of 
the solution of the chloride of arsenic, three drachms of the tincture 
of iron in a three-ounce mixture of sirup and water. A teaspoonful 
of this was given, well diluted, after each meal. At the same time 
the internal os was incised superficially in three places, dividing 
equally the circumference of the canal, and the distended Nabothian 
follicle was punctured and evacuated. 

A week after this a sound was introduced of full size, and there 
was less tenderness ; the tincture of iodine was then applied from 
just within the internal os outward. At the next menstrual period 



MEMBRANOUS DYSMENORRHCEA. 239 

she had less pain, but it lasted just as long, and she passed a mem- 
brane unchanged, except that it did not appear so thick as formerly. 

From this onward the local treatment consisted in passing a full- 
sized sound just beyond the internal os directly after the menstrual 
period, and again in two weeks, and in nearly every six days about 
two grains of iodoform mixed with vaseline were passed into the cav- 
ity of the uterus, well up toward the fundus. This local treatment 
was continued without interruption for three months, and the hrst 
prescription, after it had been taken for two weeks, was followed by 
the iodide of iron, a grain and a half three times a day. 

After the second month, and at the third menstrual period from 
the time that treatment began, she had no pain and passed no mem- 
brane. At the next period she passed several shreds, but nothing 
like a complete cast of the uterus. 

The constitutional treatment, that is, alternating between the first 
prescription of mercury and arsenic and the iodide of iron, giving 
first one for two weeks, and then the other, was continued for two 
months longer. The application of the iodoform was continued 
for one month longer, once every week, and once after her menstru- 
ation, at the end of the fourth month of the treatment. Since that 
time she has had no further trouble ; her menses are regular, lasting 
about three days, and entirely without pain or any discharge of 
membrane. 

That was her record at least one year after she gave up treatment, 
since which time I have not heard from her. 

Case II. Membranous Dysmenorrhoea occurring after Treatment 
for Anteflexion and One Miscarriage. — A lady of very high culture 
and over-refinement, of a well-marked nervous temperament, but 
otherwise of good constitution, came under my observation when 
twenty-eight years of age ; she had then been married a year and a 
half. She menstruated first at fourteen years, and continued to do 
so regularly, but with pain from the very beginning. The pain 
usually began a day or so before the fiow and gradually diminished 
after. Her suffering at each period gradually increased until her 
marriage, when it became more severe. This, and the fact that she 
remained sterile, induced her to seek advice. I found her suffering 
from anteflexion of the body of the uterus and cervical endometritis ; 
there was also tenderness of the left ovary on pressure. She was 
treated for the flexion, and completely recovered. The dysmenor- 
rhoea was entirely relieved, and she became pregnant. During her 
pregnancy she suffered very much from morning sickness, and at 
the end of the third month began to show some signs of septi- 



240 DISEASES OF WOMEN. 

csemia; she then miscarried, and the ovum was found to be macer- 
ated, and probably had been dead in utero for two weeks. She 
recovered from this and was quite well for about a year, when her 
dysmenorrhoea returned ; she then returned to be treated for what 
she supposed to be a recurrence of her former trouble, but I found 
no evidence of the former flexion. But, on inquiry, I found that 
she passed at each period a membranous cast of the uterus. The 
patient thought little of this, because in former years, while suffering 
from the dysmenorrhoea caused by flexion, she occasionally passed 
small clots which looked somewhat membranous in character, but no 
doubt were simply blood-clots. 

She was placed upon treatment similar to that employed in the 
flrst case reported, except that there was no necessity for enlarging 
the internal os as in the former case, the only difference in the local 
treatment being that I used iodine in place of iodoform during the 
last two months of the treatment ; and once, immediately after the 
menstrual period, I applied a mild solution of carbolic acid to the 
uterine cavity. 

She did not again pass any membrane after the third month of 
treatment, and her pain from menstruation entirely disappeared. 

She was dismissed at the end of four months, and two months 
afterward reported that she was pregnant. Three months after that 
time she was examined and found to be so, and was progressing well. 
Since that time I have not seen her, but have heard that she gave 
birth to a healthy child. 

Case III. Membranous Dysmenorrhoea treated by Dr. Fordyce 
Barker, of New York; Complete Recovery. — I give the history of the 
following case for two reasons : First, to show that iodoform was 
employed in the local treatment, and that the patient's recovery was 
complete ; and also to take the opportunity of stating that I believe 
that Dr. Barker was the first to employ this agent. 

The history is not altogether complete, because I obtained it from 
the patient herself, who was unable to tell all that was done for her; 
but I know positively that she suffered from dysmenorrhoea, and that 
she entirely recovered under the care of Dr. Barker, and has remained 
well for a number of years. 

This was an educated lady of a well-marked nervous temperament ; 
she began to menstruate at thirteen, and continued to do so normally 
until she was twenty-six years of age. At that time she was said to 
have had an acute attack of ovaritis, and after recovering from that 
she had dysmenorrhoea. 

The character of the pain at her menstrual periods then appeared 



MEMBRANOUS DYSMENORRHCEA. 241 

to be ovarian. After suffering in this manner for about four or live 
years she noticed the expulsion of membranous casts of the uterus 
at the menstrual periods. During this time and for a year afterward 
she was regularly treated by her family physician, but without relief. 
She then consulted Dr. Barker for her general ill-health, but did not 
call his attention to her derangement of the menstrual function. 
She improved in her general condition under his care, but fonnd no 
relief from the membranous menstruation. She consulted him again 
and called his attention to the uterine trouble, and he immediately 
placed her under treatment. 

The constitutional remedies employed I do not know, but the 
local treatment consisted in dilatation of the cervical canal and the 
application of iodoform to the uterine cavity. 

She continued to pass membrane for several months ; then the 
trouble ceased, and has not returned. She now menstruates regularly 
and naturally, and has done so for over two years. 

Several other cases might be added, some showing failure of 
treatment, and others where the patients were really made worse by 
being treated for inflammation of the uterus which was supposed to 
be the cause of the affection, but undoubtedly was not. Other cases 
might be given, also, in which recovery took place, and after several 
months or years the trouble returned, but they would add nothing 
to the views already expressed regarding the pathology and treat- 
ment of this aff'ection. 



17 



CHAPTEK XIY. 

LACERATIONS OF THE CERVIX UTERI DUE TO PARTURITION. 

Regarding this subject Dr. Thomas Addis Emmet says : " Its 
importance can not be exaggerated, since one half of the ailments 
among those who have borne children are to be attributed to lacera- 
tions of the cervix." 

This estimate of the frequency and consequences of laceration 
of the cervix uteri is quite sufficient to introduce the subject and 
secure for it special attention. 

Sir James Y. Simpson pointed out the fact that lacerations of 
the cervix uteri frequently occurred, and Dr. Gardiner also described 
such lesions and their results ; but to Dr. Emmet is due the credit 
of describing fully the pathology of lacerations of the cervix and 
their causative relations to many other uterine diseases. He also 
devised efficient surgical means for their relief. This is certainly 
the most brilliant of all Dr. Emmet's achievements. 

The disturbing influences of this injury upon the sexual organs 
and the general health are usually marked, but depend to some 
extent upon the magnitude and location of the laceration. The lirst 
effect noticed is to retard recovery after confinement. The lacera- 
tion exposes raw surfaces to the lochial discharges which, when 
these are decomposing and offensive, may give rise to septicaemia. 
Even where this does not occur the injury interrupts, more or less, 
the process of involution and produces all the troubles which usu- 
ally follow therefrom. 

There is more or less inflammatory action set up in the parts, 
and the efforts at healing the laceration develop much scar tissue 
and not unfrequently enlargement and hardening of the parts from 
areolar hyperplasia. The scar tissue thus formed and the sclerosed 
tissues beneath and around the scars are often tender and painful. 
All this proves to be a source of local irritation, and sometimes 
causes much general disturbance through reflex action. The inflam- 



LACERATIONS OF THE CERVIX UTERI FROM PARTURITION. 243 

matory action which immediately follows the injury does not entirely 
subside when cicatrization is complete. The inflammation in the 
cervical mncons membrane lingers there, and hence old lacerations 
are generally accompanied with marked catarrh of the cervical mem- 
brane. This is kept up and often aggravated by the e version or 
rolling outward of the divided walls of the cervix, which exposes 
the cervical mucous membrane to friction and the acid secretions of 
the vagina. Therefore, the cervical endometritis accompanying 
lacerations has no natural tendency to disappear. It is also rebel- 
lious to treatment, and finally, if it is subdued, it soon returns unless 
the original injury is repaired. In lacerations of long standing, and 
especially those that have been treated by caustics, the mucous folli- 
cles become closed and distended, assuming the form of small cysts. 
The presence of these distended cysts increases the size of the cer- 
vix and gives an irregular outline to the surfaces under which they 
are situated. By pressure they cause absorption of the tissues of the 
cervix, so that when they are punctured or ruptured and their con- 
tents are evacuated the cervix becomes diminished below the original 
size. 

The several forms of laceration of the cervix uteri most fre- 
quently seen in practice are : 

1. Lateral lacerations of one or both its walls. 

2. Antero-posterior laceration ; usually found in the posterior 
wall, but occasionally involving both. 

3. Multiple lacerations, usually three in number, but occasionally 
more. 

4. Incomplete lacerations, in which the solution of continuity 
extends from within outward through the mucous membrane and 
muscular walls of the cervix, but not through the mucous membrane 
of the vagina. This form of injury is generally bilateral, but occa- 
sionally the lacerations are multiple, involving the two walls laterally 
and the posterior and anterior walls also. 

Sometimes two of these forms of injury are found together, as, 
for example, a complete bilateral laceration and an incomplete lacer- 
ation of the anterior wall of the cervix. 

The first, and by far the most common of these injuries, lateral 
laceration, presents several varieties. The bilateral laceration, in its 
typical form, divides the cervix into two equal parts, and extends up 
to the vaginal junction. 

As seen at times, the laceration is superficial, extending not more 
than half way up to the vaginal junction ; again, the laceration may 
extend on one side up above the vaginal junction, while on the other 



244 



DISEASES OF WOMEN. 




it is much less extensive. In other cases the bilateral laceration 
divides the cervix into two unequal parts, the anterior portion usu- 
ally being the larger 
(Fig. 105). 

The morbid states 
of the cervix uteri 
which accompany 
this form of injury 
and are caused by it 
vary greatly. In the 
simplest forms the 
cervix, in the aggre- 
gate, is not much en- 
larged ; the divided 
halves rest nearly to- 
gether, and protect 
the mucous mem- 
brane of the cervi- 
cal canal. Under 
these circumstances 
a slight hypersemia 
of the cervical mu- 
cous membrane and a slight leucorrhoea are all the lesions present in 
many cases. Even these are not always found. 

In other cases the halves of the cervix are widely separated. 
The mucous membrane of the canal is everted, and is generally de- 
nuded of its epithelium, markedly congested, often thickened and 
irregular, and covered with a profuse leucorrhoeal discharge. In still 
other cases there is, in 
addition to the above 
e version, a marked hy- 
perplasia of all the tis- 
sues, especially on the 
inner surfaces. The 
new tissue fills in the 
space between the 
halves of the cervix, so 
that the opposite sides 
of the laceration can 
not be brought togeth- 
er (Fi^ 106\ 

\^J^. ' , , Fig. 106. — Bilateral laceration, with thickening of the 

This superabund- everted lips. 



Fig. 105. — Bilateral laceration; unequal division of the 
cervix. 




LACERATIONS OF THE CERVIX UTERI FROM PARTURITION. 245 



ant tissue is produced by arrest of involution and areolar hyperplasia. 

The tissue is denser than normal, and, in fact, presents a true sclerosis. 

Lacerations of the an- 
tero - posterior walls, while 
they are said by Emmet 
to occur frequently, are 
comparatively less often 
seen, because they generally 
heal promptly and com- 
pletely of their own accord. 
Where they are found, they 
are generally complicated 
with all the lesions de- 
scribed in connection with 
lateral injuries. 

Multiple lacerations vary 
greatly in number and ex- 
tent. A trilateral laceration 
is most frequently met with. 
The cervix is usually di- 




FiG. lOY. — Extensive multiple lacerations. 



vided into three unequal parts, as seen in Fig. 107. 

This may be called a complete multiple laceration, because all 
the tissues of the cervix are 
divided. There is another 
form of this injury in which 
there are a number of lacer- 
ations which extend from 
within outward, but do not 
involve the vaginal mucous 
membrane (Fig. 108). 

The lateral incomplete lac- 
eration may be unilateral or 
bilateral. G-enerally, both 
walls are divided from within 
outward to the outer mucous 
coat. This injury is over- 
looked quite often by gynecol- 
ogists. At least, I infer this 
from the fact that Dr. Em- 
met is the only writer of all 
those whose works I have 
consulted wdio mentions it. 




Fig. 108. — Multiple ineomplote laoorations. 



246 



DISEASES OF WOMEN. 




It is usually described as a patulous or dilated condition of the 
cervix, and to tlie touch and inspection it appears to be so, but a 
careful examination shows that the cervix is divided into two parts 

that are held together by the 
outer coat, or mucous membrane. 
Fig. 109 shows the lesion. 

This lesion can be most con- 
veniently demonstrated by pass- 
ing the uterine sound into the 
cervical canal, and then carrying 
it outward in the line of the 
laceration, w^hen it will become 
apparent that the outer coat of 
the cervical wall is all that re- 
mains intact. There is usually 
no eversion of the mucous mem- 

FiG. 109. — Incomplete bilateral laceration. ^ i - i . i -i 

brane, but almost always there 
is a marked catarrh of this membrane, which is peculiarly resistant 
to treatment. In a number of these cases I have found enlargement 
of the anterior half of the cervix which gave a crescentic appearance 
to the OS externum, Fig. 111. 

Causation. — Laceration of 
the cervix is usually caused by 
parturition, either natural or in- 
strumental. In a great majori- 
ty of first labors the cervix is 
injured to some extent, but in 
many the laceration either unites 
or, being very superficial, gives 
no trouble and passes unnoticed. 
Certain conditions of the tissues 
of the cervix predispose to lac- 
eration. Irregular development 
of the cervix either before or 
during pregnancy, in which one 
wall is thicker than the other ; 
induration from previous dis- 
ease, which lessens the elasticity 

of the tissues ; and a softened oedematous condition of the cervix^ 
produced by pressure in tedious labors — all these favor laceration. 

In abnormal labors requiring manual and instrumental aid be- 
fore the cervix is dilated there is additional liability to injury, and 



^■MH^^^"^' 


-^ 


^ 


MM^S^-Mp ti 






^^^Btff^&%^/' 


i 


"■■ 





Fig. no. — The incomplete bilateral lacera- 
tion shown in Fig. 109, as seen by sec- 
tion of the cervix. 



LACERATIO:^S OF THE CERVIX UTERI FROM PARTURITION. 247 




Fig. 111. — Crescentic laceration. 



this frequently occurs ; but it is also a fact that lacerations often take 
place in perfectly easy and natural labors. Indeed, it appears that 
in easy and rapid labor lacer- 
ations are very likely to oc- 
cur, such frequently showing 
that precipitate delivery is a 
cause of this accident, Dr, 
Emmet states in his book 
that he has seen laceration 
of the cervix in cases of 
criminal abortion. I have 
never seen laceration of the 
cervix after abortion from 
any cause at or before the 
third month of gestation. 
There is a condition of en- 
largement of the cervix with 
e version of the mucous mem- 
brane of the cervical canal 
which presents all the phys- 
ical signs of a superficial 
bilateral laceration, and this 

I have seen after abortion in the first pregnancy, but 1 have also seen 
the same condition in the virgin uterus. This affection is described 
under the head of cervical endometritis, and, therefore, need not be 
discussed herCo 

From what has been said, it will appear certain that this injury 
can not at all times be prevented by any skill and care on the part of 
the obstetrician. This should always be borne in mind and freely 
stated where the injury is attributed to carelessness on the part of 
the attendant during labor, a mistaken criticism not uncommonly 
heard among the laity. 

The effect of this injury upon the uterus and the general health 
of the patient, together with the symptoms and physical signs, will be 
brought out in full in the histories ofi llustrative cases which follow. 

The treatment of this injury includes the primary and secondary 
management. It has been suggested that when the injury takes 
place the laceration should be immediately closed with sutures, but 
this is impracticable. First, because it is impossible to fully estimate 
the extent of a laceration in the relaxed condition of the cervix im- 
mediately after delivery ; and, secondly, the dithcultv of accurate- 
ly adjusting sutures under the circumstances would subject the pa- 



248 DISEASES OF WOMEN. 

tient to exposure, which is unwarranted. Besides this, the intro- 
duction of sutures and the disturbance of the tissues necessary to 
their introduction would tend to interfere with spontaneous union, 
a favorable termination not infrequently attained. The primary 
treatment then must be limited to the usual means employed 
by the competent obstetrician to secure normal involution of the 
pelvic organs. The secondary treatment should embrace three 
objects : First, to overcome the consequences of the injury ; sec- 
ond, to improve the nutrition of the parts injured, and thus pre- 
pare them for the third step, the repair of the laceration by surgical 
means. 

AYhen an improvement in the condition of the tissues of the 
uterus is attained, the general health of the patient is usually bene- 
iited by securing the best conditions for success in the operation 
for restoring the laceration. In order to do this it is necessary to 
overcome as far as can be the endometritis which usually accompa- 
nies the injury. The means used for this purpose sometimes suc- 
ceed in relieving the subinvolution which usually is present in those 
cases. Where there is much enlargement of the cervix from areolar 
hyperplasia, which makes it im|)ossible to bring the divided edges 
together, and all ordinary treatment fails to reduce this enlargement, 
it is sometimes necessary as a preparatory measure to remove a por- 
tion of the tissue on the inner sides of the divided halves of the cer- 
vix and allow the parts to heal before performing the final opera- 
tion. This I have usually accomplished by taking out a section on 
each inner side of the halves and bringing them together with a 
couple of sutures. These are left in place for a week or two, and in 
the mean time the hot-water douche should be used, and such local 
applications as may be necessary to relieve catarrh or hypergemia. 
The sutures are then removed, and after a few weeks the operation 
for the restoration of the cervix is performed. When there are a 
number of cysts in the cervix (a condition known as cystic degenera- 
tion) they should all be opened and evacuated. Sometimes the 
everted mucous membrane becomes very much thickened, and pre- 
sents a granular or papillomatous-looking surface. When such is the 
case, it is best to trim off the more prominent points on the surface, 
and subsequently make such application as will reduce the thicken- 
ing and vascularity of the membrane. 

It has been suggested by some that whenever there is a laceration 
it should be at once restored. Such authorities are of the opinion 
that if the operation is successful the other pathological lesions which 
were caused originally by it will disappear eventually. This is not 



LACERATIOI^S OF THE CERVIX UTERI FROM PARTURITION". 249 

by any means to be relied upon, and I mncli prefer to remove, as far 
as possible, all local complications before operating. 

The objects to be obtained by the operation are to remove the 
scar tissue formed by the healing of the ununited edges of the lacer- 
ation, and thereby relieve the pain and reflex disturbances which 
it may have given rise to, and also to close in the mucous mem- 
brane and protect it from further irritation. There is still an- 
other important benefit gained by the operation — viz., when the 
uterus is larger than normal, owing to subinvolution, a marked 
reduction in its size will follow after this operation. I beheve 
that the completion of involution generally follows successful res- 
toration of the cervix, excepting in those who have had puerperal 
metritis. 

In recent superficial lacerations I have operated without an£es- 
thetizing the patient. The pain of the operation is trivial compared 
with the distress from the after-effects of an anaesthetic. As a rule, 
however, it is necessary to administer an angesthetic, especially in 
deep lacerations of long standing, w^here there is much scar tissue 
and consequent tenderness. 

The operation for the restoration of the cervix uteri must vary 
a little in detail according to the nature of each form of injury, 
but the operation, as performed on the bilateral, uncomplicated 
form of laceration, illustrates in the most perfect way the mech- 
anism and details of the operation. I will, therefore, describe 
the operation in this form of laceration, and give cases the histo- 
ries of which will illustrate the necessary modifications in the other 
forms. 

The operation is performed as follows : The patient is placed 
upon the left side, and a Sims's speculum introduced and held by 
a trained nurse or assistant. A tenaculum forceps, curved upon the 
flat side, is fixed in the anterior half of the cervix, at the point which 
makes the lip of the os externum. The posterior half of the ceiwix 
is seized in the same way with a similar forceps, and the operator, 
taking a forceps in each hand, brings the two flaps together, in 
order to see exactly where the parts are to be united. The forccj^s 
w^hich holds the anterior flap is then given to an assistant, while 
the one attached to the posterior flap is held in the left hand of tlie 
operator, and the surfaces are denuded by the hawk-bill scissors. Fig. 
112. 

The points of the scissors are made to seize the angle formed by 
the junction of the two flaps as far up as appears necessary to denude 
them. The flaps are brought together bv the aid of the forceps on 
IT* 



250 



DISEASES OF WOMEN. 



eacli side, so as to briDg the tissues more witliin the grasp of the 
scissors. 

The blades of the scissors are then closed, and a strip is removed 
from above downward on each flap. The other side is treated in 




Fig. 112. — Hawk-bill scissors. 

the same way, and the most important part of the denudation is com- 
pleted. It frequently happens that a portion of the tissue to be so 
removed escapes from the scissors at the lower portion of the flaps 
on one or both sides ; but when this hap|)ens, the denudation is 
easily completed with the ordinary curved scissors. If the curved 
scissors only are used, much difiiculty is experienced in vivifying 
the upper angles of the laceration, but with the hawk-bill scissors 
this portion of the operation can be accomplished accurately and 
with facility. The hawk-bill scissors, while saving time and trouble, 
give smoother surfaces for coaptation than can be otherwise ob- 
tained. A faithful trial of both methods by myself, and observa- 
tions of the old method as practiced by the most expert surgeons 
convince me of this fact. It has been said that all the cicatricial 
tissue can not be removed with the hawk- bill scissors. In regard to 
that, I can say that I have always succeeded in removing all that 
was necessary to secure good union and satisfactory ultimate results. 
Fig. 113, colored plate, shows the two denuded surfaces on each side 
of the laceration and the strip of the mucous membrane between. 
The needles used are triangular and pointed. Three lengths are 
convenient to have, but the medium one can be made to answer for 

all. The shape and length of 
these are shown in Fig. 114. 

The needle-forceps described 
in connection with the operation 
for restoration of the pelvic floor 
is used for this operation. 

The sutures are introduced in 
the following manner: The nee- 
dle is placed in that groove of the 
Fig. 114.— Triangular needles. needle - forceps which will give 



1 






1 


) 


i ^ 


3 

i GEO. 


4 

TIEMANN 


5 

&C0. 


6 


' 


1 









PLATE III 

Opekation foe Laceration of the Cervix Uterl 

Figure lis. Page 250. 
Denudation complete. 

Figure 116. Page 253. 
The sutures in position. 



Figure llT. Page 25S. 
The sutures tied. 




PLATE ill 



FIG. 113 

PAGE 250. 




FIG. 116 
PAGE 253. 




FIG. 117 
PAGE 253 



LACERATIONS OF THE CERVIX UTERI FROM PARTURITION. 251 

the desired angle, and is held immovable there, while the operator 
grasps the handle and closes the catch. The needle is then passed 
into the tissue, and left there while the forceps is unclasped and 
reversed. Its other end is then used to grasp the point of the 
needle and draw it through. The first two sutures are introduced 
at the lower end of the flaps, at points corresponding to the sides 
of the OS internum. In some cases, when the parts do not come 
together easily, it is well to introduce first a suture on each side at 
the upper end of the wound, and then the two lower ones. While 
introducing the first two sutures the parts are held by the tenaculum 
forceps, which were used during denudation. As each suture is 
introduced, the ends are united by passing one around the other in 
a loop-knot. This keeps the sutures from being tangled. 

The tenaculum forceps is then removed, and, while an assistant 
steadies the cervix by holding the ends of the first sutures, the others 
are introduced, a tenaculum being used to make counter-pressure 
while the needle is passed. 

The sutures are tied as follows : One or two turns of the ends 
are made to form the first half of the knot, the assistant takes hold 
of one end, the other is passed through the loop of a counter-pressure 
instrument, and then seized by the left hand of the operator. Trac- 
tion is then made on both ends of the suture, and, at the same time, 
the loop of the instrument is pushed down along the thread to make 
the knot slip to its destination. Repeating this manoeuvre completes 
the knot. The instrument used is about the size and shape of an 
ordinary Sims's tenaculum, but, in place of having a hook-point, it 
terminates in a ring (Fig. 115). 



-G^TIEMANN 8cC0T 



Fig. 115. — Eing-tenaculum or counter-pressure instrument. 

• By this method the sutures can be tied about as easily and rap- 
idly in the cavity of the vagina as upon a free surface. The ends of 
the sutures are then cut off, and a small tampon of well-dressed flax, 
saturated wath pine tar (marine lint), is carefully packed in, flrst 
around the cervix, and then below it. This tampon makes a good 
antiseptic dressing. It promptly absorbs serous oozing, and pre- 
vents any motion of the uterus which might strain the sutures. xVt 
the end of forty-eight hours it should 1^ removed, and, if the parts 
are then in a healthy condition, no further local treatment is required. 
If there is any suppuration, a fresh tampon should be inti'oduced, 
and allowed to remain for forty-eight hours longer. 

From my experience in a large number of cases, I am satisfied 



252 DISEASES OF WOMEN. 

that the use of the tampon is a reliable after treatment in this opera- 
tion, and is preferable to the daily injection of carbolized water, 
which so many employ. 

The patient should rest in bed, with the privilege of turning 
upon either side. The bowels and bladder should be evacuated upon 
the bed-pan. 

The sutures should be removed upon the eighth or ninth day. 
If union is imperfect, the lower ones may be left in for two weeks. 

The simplicity of the after treatment is its chief merit. Keep- 
ing the patient perfectly still in bed is a great punishment to one in 
good general health, and tends to prevent union ; hence, giving 
the patient the pri\dlege of tossing about on the bed is a great com- 
fort. I am inclined to think that I could give the patient liberty to 
get out of bed to evacuate the bowels and urinate, if the tampon was 
employed continuously. As bearing on this point I may refer to 
the case that I operated upon in my office, and sent home in the 
street-cars. She made a perfect recovery. Another case shows what 
can be done with impunity. A patient of Dr. George T7. Baker's, 
a very strong, active lady, was operated upon for a bilateral lacera- 
tion in the usual way. She refused to stay in bed, but rested on the 
sofa, and visited the water-closet when necessary. Her menses came 
on prematurely and profusely. A large coagulum formed in the 
vagina and was passed while straining in the water-closet, l^ot the 
sKghtest hope of success was entertained, but on removing the 
sutures the results were found satisfactory in every way. These 
cases con^dnced me that the absolute quietude usually insisted upon 
is not necessaiw, and hence since then I have given more liberty of 
action. Much discomfort is avoided in this way, and the patient 
gets up better and stronger. 

ILLrSTEATIVE CASES. 

Typical Case of Bilateral Uncomplicated Laceration of the Cervix 
Uteri. — The patient was twenty-four years of age, and had her Urst 
child fourteen months before she was first examined. Her general 
health was fairly good, but she had backache and profuse leucor- 
rhoea. AYalking or standing gave her pelvic tenesmus, and she was 
more easily fatigued than in former years. She began to menstruate 
ten months after her confinement, and gave up nursing her child 
when it was a year old. The menses were normal, but more free 
than formerly, and lasted a day longer. She was sterile. Physical 
examination showed that the uterus was a little larger than it usually 
is in a person of her size. The cervical mucous membrane was 



LACERATIONS OF THE CERVIX UTERI FROM PARTURITION. 253 

hjperaeniic, and denuded of epithelium in certain places. There was 
a profuse leucorrhoea. 

The cervical canal was cleared of the leucorrhoeal discharge, and 
an application of equal parts of tincture of iodine and carbohc acid 
was made. Tliis was repeated at the end of a w^eek and after the 
succeeding menstruation. The cervix was restored in the way al- 
ready described without using an anaesthetic. 

Figs. 116 and 117, colored plate, show the cervix with the sutures 
in position. A marine-lint tampon was used and kept in position 
for forty-eight hours. 'No after treatment was needed. The sutures 
were removed on the tenth day, and the union w^as complete. The 
patient was kept in bed two weeks in all, and during that time was 
given a good, generous diet, and her bowels were moved daily. She 
had no pain during her rest in bed, and, although weak when she 
first tried to walk, she soon regained her strength. After the re- 
moval of the sutures a vaginal douche of borax and water was used 
up to the time of the next menstrual period. Three months after 
the operation she was free from all her former symptoms. The 
cervix then appeared like that of an imparous uterus. 

Bilateral Laceration complicated with Enlargement of thfe Cervix 
from Hyperplasia. — This patient had her only child when she was 
twenty-six years old. Her labor was tedious, but otherwise normal. 
From the time of her confinement until I first saw her, four years 
afterward, she had not been well. She suffered from backache, pel- 
vic tenesmus, and profuse leucorrhoea. Her general health, which 
was formerly very good, became impaired. The appearance of the 
cervix when first seen is shown by Fig. 106. 

It was impossible to bring together the edges of the os exter- 
num, owing to the enlargement of the halves of the cervix. Consti- 
tutional treatment was employed, and the hot-water douche and 
tincture of iodine used locally, but at the end of two months there 
was only a slight improvement in the condition of the cervix. A pre- 
liminary operation was then performed as follows: A crescentic- 
shaped piece of tissue was removed from the inner side of each 
half of the cervix sufficiently deep to permit the halves to be 
brought together with very little traction. Fig. 118 shows the por- 
tions removed, the dark lines indicate the lines of incision. Two 
sutures, one on each side of the os externum, were introduced to 
hold the parts together while lieahng w'as going on. Figs. 119 and 
V20 show the parts brought together with the sutures, and Figs. 
121 and 122 show a different method of doing the same operation. 
Eofore tying the sutures a piece of muslin saturated with wax wos 



25i 



DISEASES OF WOMEN". 



placed between the halves of the cervix, and left there for four 
days to keep the ccaptated parts from meetiug. The sutures were 






FiPx. 118. Fig. 119. Fig. 120. 

FiG.^ 118. Removal of crescentic shaped piece (seen in section) when the everted lips are 

thickened. Figs. 119 and 120. Method of bringing the sides of the sections together. 

removed at the end of two weeks, when it was found that the parts 



where the exsections were made had 





nearly healed over. Three 
weeks afterward the cervix 
restored in the usual 



was 



was 



Figs. 



Fig. 121. 
121 and 122. 



Fig. 122. 
-Another method of closin 
gap. 



the 



way, and good union 
obtained, and the patient 
subsequently recovered. 

In cases like this I have 
sometimes removed the re- 
dundant tissue of the cer- 
vix at the time of perform- 
ing the final operation for 
the restoration of the cervix. "Wlien this h done, it is necessary to 
keep a plug in the cervical canal during the healing process in order 
to prevent the vivified portions from uniting. 

I much prefer to do the preliminary operation, believing that I 
can get better results by so doing. 

Laceration of the Posterior Wall of the Cervix Uteri, complicated 
with. Ealargement of the Cervix and Cystic Degeneration of the Mucous 
Membrane. — The patient was first seen when thirty-four years of age, 
and had been married thirteen years. The injury of the cervix oc- 
curred twelve years before, when she had her only child. She got 
up from her confinement with leucorrhoea, backache, and pelvic 
tenesmus, and continued to sufier from these for about one year, 
when, becoming tired of being told that her pelvic symptoms would 
disappear when she gained her strength, she consulted another phy- 
sician. Local treatment was then employed with benefit, but it 
proved to be temporary. The leucorrhoea and other symptoms 're- 
turned in an aggravated form. She continued in this way, getting a 
little temporary relief from treatment and again going uncared for. 



LACERATIONS OF THE CERVIX UTERI FROM PARTURITION. 255 

up to the time that slie came under my care. For three montljs 
she was treated for cystic degeneration, catarrh, and hypertrophy of 
the cervix. The latter appeared to be due to imperfect involution 
and hyperplasia combined. The laceration extended up to the vagi- 
nal junction, and there were erosion and eversion, but not to any 
great extent. In restoring the cervix, its sides were seized with the 
tenaculum forceps, and the upper angle of the laceration vivified 
with the hawk-bill scissors. The denudation was carried down- 
ward to the OS externum with the curved scissors. The introduc- 
tion of the sutures and the after-treatment were conducted as 
usual. The union was satisfactory in every way. There was no 
return of the former symptoms, and she was classed among the suc- 
cessful cases, although she remained sterile without any apparent 
cause for ito 

Multiple Laceration of the Cervix. — A large, muscular lady had her 
first child when she was twenty-six years old. Her labor was tedious, 
the membranes rupturing before the cervix was fully dilated. Man- 
ual dilatation was resorted to, and the forceps used to deliver before 
the head had fully descended into the pelvis. This much of the 
history was obtained from the physician who attended her in confine- 
ment. Four years subsequently I first examined her and found a 
multiple laceration of the cervix. The irregular nodulated state of 
the cervix and its density to the touch suggested the thought that 
there might be malignant disease present. This suspicion w^as still 
further aroused by a speculum examination, which revealed a profuse 
leucorrhoea and a rough, vascular, papillomatous state of the mucous 
membrane. The fact that the parts improved promptly on treat- 
ment settled the diagnosis. The cervix was divided into three un- 
equal parts (Fig. 108). For two months she was treated for the in- 
flammation of the cervix, and at the end of that time the laceration 
of the posterior wall was operated upon in the usual way. It was 
not necessary to anaesthetize the patient, as the operation required 
only a short time and was not very painful. She was kept in bed 
for a week, and good union was obtained. This left the patient 
with a simple bilateral laceration, which was successfully operated 
upon five weeks afterward. 

Multiple Laceration incomplete, complicated with Endometritis Poly- 
posa. — The patient was thirty -seven years old, married seventeen 
years, and had borne three children, the youngest of whom was two 
years of age. It was impossible to ascertain when the cervix was 
injured. The history showed that her health began to fail after the 
birth of her second child, and that she broke down completely afte» 



250 DISEASES OF WOMEN. 

her third one was born. When she came under my observation she 
had menorrhagia, a poor appetite, and constipation. She was ema- 
ciated, very anssmic, irritable, sleepless, and suffered much from 
headaches — in short, was perfectly useless, and a great sufferer. She 
had free leucorrhoea, backache, and ovarian pain, which was at times 
quite annoying. 

The physical signs indicated that there was a polypoid state of 
the endometrium. There were four lacerations of the cervix. Two 
lateral, the largest, and one in the anterior wall and another in the 
posterior wall. These latter might be called fissures. They did 
not extend through the whole of the middle coat of the cervix. 
The lateral lacerations were complete, involving the entire wall of 
the cervix for about a quarter of an inch below and were incom- 
plete above. The fungosities of the endometrium were removed 
with the curette. This relieved the menorrhagia and improved the 
general health of the patient to some extent. The restoration of 
the cervix was effected by operating upon the lateral lacerations in 
the prescribed way, i. e., first making complete lacerations of them, 
and then vivifying the parts and closing them with sutures. The 
antero-posterior lacerations or fissures were treated by vivifying 
their sides as well as could be done before closing the lateral 
ones. When the sutures were tightened in the lateral lacerations 
it was found that the traction appeared to hold the antero-posterior 
lacerations together. The result proved that such was the case. 
There was good union, and the patient gained in strength rapidly 
and was quite well at the end of three months. 

Typical Case of Bilateral Incomplete Laceration of the Cervix 
Uteri, — The patient, a lady of excellent physique, married at thirty- 
one years of age, and had her first child three years later. Her labor 
was tedious in the first stage, but her recovery was without any 
marked interruption. When her child was twenty months old she 
became pregnant again, and miscarried at the third month. Six 
months after her miscarriage she was first examined. She then 
suffiered from menorrhagia, pelvic tenesmus, and profuse leucor- 
rhoea, which caused some general depression — but not to any great 
extent. The uterus was retro verted, and the cervical canal admitted 
the index-finger nearly to the internal os. The uterus was a little 
larger than normal, and its mucous membrane congested and irregu- 
lar to the touch of the sound. 

The uterus was restored to its position and retained there with 
a pessary. The canal of the cervix was touched with tincture of 
iodine. This gave her relief from tenesmus, but did not control 



LACERATIONS OF THE CERVIX UTERI FROM PARTURITION. 257 

the menorrhagia nor the leucorrhcea. Subsequently the cavity of 
the uterus was curetted, and carbolic acid and iodine were applied 
to the canal of the cervix. From this time on the menses were nor- 
mal, but the leucorrhcea returned again and again. Treatment 
would arrest it for a time, but it returned, and she proved to be ster- 
ile. Restoration of the cervix was proposed in the hope that the 
operation would give her permanent relief. 

The operation was performed as follows : Taking hold of the 
anterior and posterior walls of the cervix with the tenaculum for- 
ceps, a straight scissors was passed into the cervix half its entire 
length, and the mucous membrane of the vagina (the portion of the 
cervical waU which escaped laceration) was divided. The other side 
was treated in the same way. The halves of the cervix were drawn 
apart, so that the extent of the internal laceration could be clearly- 
seen, and then the angle on each side was vivified with the hawk- 
bill scissors. After this there still remained a little redundant vagi- 
nal mucous membrane at the lower portion of the cervix, and be- 
tween the vaginal and cervical mucous membrane the site of the 
laceration, the muscular walls remained modified. The redundant 
vaginal membrane was removed and the middle walls of the cervix 
were vivified with the curved scissors. This modification of the 
method of vivifying the parts to be united became necessary because 
of the lacerations being incomplete, ^ 

In some cases of incomplete laceration when the cervix is large, 
it is best to divide the vaginal mucous membrane first. By using 
the hawk-bill scissors a Y-shaped piece can be taken out on each side 
which completes the vivifying with a single clip of the scissors on 
each side. 

The sutures were introduced and the operation completed in 
the usual way. The case progressed favorably, union was complete, 
and there has been no return of the leucorrhcea nor any of her for- 
mer symptoms. 

Incomplete Laceration with Hypertrophy of the Anterior Half of the 
Cervix. — The patient had suffered from a profuse leucorrhcea since 
the birth of her child five years before. She had been treated oc- 
casionally, and derived only temporary relief, the symptoms return- 
ing again when treatment was suspended. The enlargement of the 
anterior half of the cervix was confined mostly to the mucous mem- 
brane. This gave a crescentic appearance to the os externum (Fig. 
112). The treatment consisted of exsection of the hypertrophied 
portion of the mucous membrane in the anterior wall, and when 
the parts had healed the laceration was operated on in the same 
18 



258 DISEASES OF WOMEN. 

manner as in the case of incomplete laceration preceding this 
one. 

The exsection was made by seizing the part to be removed with 
a tissue forceps, and with a shghtly-curved scissors, clipping off the 
whole of the mucous membrane on that side up as high as the hy- 
pertrophy extended. There was some bleeding, but that was very 
easily controlled by packing the cervical canal with cotton, and 
using a vaginal tampon to keep it there. 

The Results of the Surgical Treatment of Lacerations of the Cervix 
Uteri. — There are some points that remain to be settled by reliable 
observations regarding the results of the surgical treatment of these 
injuries. More statistics by reliable observers are needed to deter- 
mine definitely all the benefits which may be reasonably expected 
from this form of treatment. 

It may be fairly claimed that successful restoration of the cervix 
will relieve the inflammatory troubles of the cervix, including the 
suffering from scar tissue in the great majority of cases. 

Sterility due to the injury of the cervix and the consequent le- 
sions is cured in many cases. 

Labor is not, as a rule, retarded by the condition of the cervix 
after the operation. Nor does laceration necessarily occur again. 
I have been able to compare the dilatability of the cervix after 
trachelorraphy with that of lacerated cervix with scar tissue, and I 
have found that the results are greatly in favor of those patients in 
whom the cervix has been restored. 



CHAPTER Xy. 

CICATEICES OF THE CERVIX TJTEKI AND VAGINA. 

Cicatrices, the results or products of diseased action and inju- 
ries, are of pathological importance according to their size and loca- 
tion. They derange the conditions of health and comfort by the 
tender and painful character of scar tissue, and by its inelasticity, 
which interferes with the free motion of the pelvic organs. The 
slow, persistent contraction of this abnormal tissue, by which the 
adjacent normal parts are united, causes pain by making pressure on 
the terminal nerve-iibers. Tenderness, also a characteristic of scar 
tissue, is developed in the same way, or perhaps from the excessive 
irritability or imperfect protection of the nerves found in cicatrices. 
This tenderness is most marked in scars at or near the introitus 
vaginae, and varies according to the age of the new tissue. When 
an uninterrupted cicatrix surrounds the cervical canal, the os ex- 
ternum, or the vagina at any point, stenosis is produced, and all the 
derangements consequent thereon, according to the partial or com- 
plete development of the stricture. 

Causation. — The causes which lead to the formation of cicatrices 
are familiar to all, and require only to be named in order to recall 
them for present consideration : Injuries during parturition suffi- 
cient to cause sloughing or loss of tissue ; lacerations which heal over 
without uniting the divided parts, or which are united by interven- 
ing new tissue ; amputation of the vaginal portion of the cervix ; 
exsection of a portion of the vagina, especially where healing takes 
place by granulation ; destruction of the mucous membrane and sub- 
jacent structures by the free use of caustics, and extensive ulceration 
either simple or specific. These are the chief affections which give 
rise to the conditions now under consideration. 

Symptomatology. — The symptoms developed by cicatrices are 
pain, which is often intermittent or remittent, and is usually in- 
creased by exercise. When the scar involves the circumference of 



260 DISEASES OF WOMEN". 

the cervix, and tlie caliber of the canal is reduced below the normal 
size, dvsmenorrhcEa occurs in some cases. "When the vagina is ex- 
tensively involved, the functions of the bladder and rectum are occa- 
sionally deranged so as to give rise to frequent and difficult urination 
and painful defecation. This is due, doubtless, to the tenderness of 
the scar tissue, and diminished mobility of the parts. For the same 
reason, coition is painful, and in some marked cases impossible. It 
will be observed that the same derangement of the sexual function 
occurs in vaginitis, vaginismus, and in that rare neurotic affection 
in which there is extreme hyperaesthesia without any apparent 
change of stnicture or circulation to accoont for it. In short, any 
or all of the symptoms caused by cicatrices may arise from other 
pathological conditions, such as are found, for example, in conva- 
lescence from pelvic peritonitis or cellulitis. On that account the 
diagnosis must be based chiefly on the physical signs. These I may 
briefly mention. They are the presence of abnormal tissue, which 
is usually tender, always indurated, less elastic than healthy parts, 
and sometimes lighter in color, and having a smooth surface. Cica- 
trices of the vagina are easily detected ; those of the cervix are liable 
to be confounded with sclerosis and incipient malignant disease. 
The points of distinction are the increase of tissue and abnormal 
vascularity found in the latter. 

Knowing the evils which cicatrices give rise to, the first duty of 
the practitioner is to guard against their formation. This can be 
accomplished to a great extent, I am sure, by observing certain lines 
of practice. Lacerations of the pelvic floor, occurring during nat- 
ural or artificial delivery, should be immediately brought together 
by sutures, when it is possible to do so, in place of leaving them to 
heal as best they may, which is the usual practice. In many such 
cases the patient is ansesthetized when the injury is sustained, and, 
if the obstetrician has the requisite instruments at hand — as he ought 
to have — the operation of closing such wounds with sutures is prac- 
ticable ; if such wounds can be made to heal without the interven- 
tion of much new tissue, the cicatrices are very unimportant com- 
pared with the large scars which are sometimes formed where heahng 
takes place by granulation. 

In making these statements, I am aware that the ground taken 
may be questioned. In opposition to this practice, it may be said 
that such wounds often heal promptly without the aid of sutures, 
and even when sutures are employed there is no certainty that good 
union will take place. On the other hand, it can be fairly claimed 
that, if the edges of a lacerated wound are held together, the chances 



CICATRICES OF THE CERVIX UTERI AND VAGINA. 261 

of tlieir uniting are better than if left alone. Even should healing 
take place by granulation, the sutures, preventing the wide separation 
of the parts, will tend to lessen the size of the cicatrix. When there 
is so much to be gained by good union, and so much suffering en- 
tailed by bad, the use of sutures in such cases is surely good surgery. 

The formation of troublesome cicatrices following the use of 
caustics may be prevented by carefully circumscribing the space to 
which they are applied, and by avoiding their use to an extent suf- 
ficient to cause destruction of the deeper structures of the mucous 
membrane. "When it is necessary to apply a caustic — say nitric acid 
— to the OS externum or cervical canal, a portion of the membrane 
should be left untouched if possible, so that the eschar, if one is 
formed, will not completely circumscribe the canal. By attention 
to these points, cicatrices may be prevented, or, if they follow, they 
will be less troublesome in character. 

In amputating the cervix, that method of operating should be 
chosen which will secure the most serviceable stump. The flap or 
circular amputation, in Avhich the mucous membrane is brought over 
the stump and held in place by sutures according to the methods of 
Sims or Schroeder, gives the most satisfactory results, esjDecially so 
where the parts heal promptly. When suppuration occurs, and the 
parts heal by granulation, the stump is less perfect ; but even then 
it is better, as a rule, than when the stump is left unclosed. 

Treatment. — In the treatment of cicatrices the chief indications 
are to relieve the pain and tenderness of the parts, prevent contrac- 
tions, and, where deformities exist, to correct them. These require- 
ments can be most promptly and perfectly fulfilled by removing the 
whole of the cicatrix, and bringing together the normal tissues, and 
obtaining as near immediate union as possible. But this radical 
treatment is only called for in rare cases, and is not always practica- 
ble, owing to the size, depth, and unfavorable location of the cica- 
trix. Exsection should not be undertaken in any case unless the 
scar is movable on the subjacent tissue. It is necessaiy to wait 
until this mobility is established, which usually occurs sooner or later. 
When the scar can not be removed altogether, contraction should 
be guarded against by preventing it from shortening. In oblong 
cicatrices, contraction in width rarely gives trouble, while shorten- 
ing causes deformity. This can often be prevented by dividing the 
scar at one or more points, and then putting the parts on the stretch 
by the tampon or pessary. The divided edges thus held apart are 
united by intervening new tissue, and the scar is lengthened, while 
the process of narrowing still continues. Sometimes the contractility 



262 DISEASES OF WOMEN". 

of the normal tissues is sufficient to draw tlie divided edges of the 
scar apart, so that incising the scar is all that is necessary. 

When a cicatrix surrounds the os externum, it should be divided 
on two sides, the lateral being preferable in most cases ; a tent of 
sea-tangle should then be introduced and worn during the process 
of healing. The tent should be short, so as not to enter the internal 
OS, and it can be held in position by a pessary by stitching it to the 
walls of the cervix. The frequent use of the sound or dilator will 
answer the same purpose. 

In the management of cicatrices of the vagina, very satisfactory 
results are obtained by the treatment proposed. After dividing the 
cicatrix, the parts are put upon the stretch by the glass dilator em- 
ployed by Sims and others in the treatment of atresia vaginge. I 
have also used for the same purpose elm-bark, made into a roll of 
the proper length and thickness, and beaten until it is soft. It is 
then dipped in carbohzed water, and introduced like a pessary. This 
has the advantage of being agreeable to the tissues, and by expand- 
ing very slowly it causes distention, which is easily borne. By en- 
larging the size used from day to day, the vagina can be distended 
slowly and without pain. I am satisfied that this method of treatment 
has another advantage, which is, that by slow, continuous dilatation 
the normal portions of the vagina can be developed so as to compen- 
sate for the contraction of the cicatrix to a very considerable extent. 

When there is no considerable deformity, and pain and tender- 
ness are the only symptoms, the most marked relief will often follow 
an incision of the cicatrix at a number of points. I have also been 
led to believe that softening of the scar and relief from pain were 
obtained by the frequent application of equal parts of tincture of 
opium, aconite, and iodine. 

A word might be said about complications, such as vaginitis, 
cervical endometritis, etc. They are to be treated in the usual way, 
of course. I need only add that, so far as my observations have ex- 
tended, it has been found that by relieving trouble caused by cica- 
trices, recovery from accompanying affections is facilitated. This is 
as might be expected. 

ILLUSTRATIVE CASES. 

Scar Tissue producing Stenosis of the Vagina. Primary Cause ; 
Acute Inflammation during the Course of the Fever. — A lady, thirty 
years of age, large, well formed, and in general good health, men- 
struated first at fifteen years of age, and has continued to do so 
regularly and normally ever since. She has been married twelve 



CICATRICES OF THE CERVIX UTERI AND VAGINA. 263 

years, and during that time coition has been impossible. Before 
marriage she had no symptoms of uterine disease, but soon after she 
developed uterine and vaginal leucorrhcea, which have continued in- 
termittently ever since. She has also suffered occasionally from 
backache and irregular pains in the pelvis. Examination by the 
touch revealed contraction of the whole vagina, so that the index- 
finger could with difficulty be introduced, and at the upper portion 
there was a stricture through which the finger could not be passed. 
In a pocket beyond the stricture the cervix uteri was subsequently 
found. The stricture was due to scar tissue, which formed a circular 
band about a quarter of an inch wide. From this ring, extending 
downward, there was another cicatrix which terminated at the re- 
mains of the hymen. There was subacute vaginitis and the papillae 
of the mucous membrane were enlarged and exceedingly tender. 
The examination caused intolerable pain. At another time an anges- 
thetic was given and the stricture divided. The uterus was then 
found to be normal in size and shape, but there was a little erosion 
about the os externum and congestion of the cervical mucous mem- 
brane and hypersecretion. 

]^othing in the history of the case, nor in the local lesions, gave 
any clew to the cause of the trouble, but on re-examination it was 
found that when the patient was a child she had what was called 
typho-malarial fever followed by pelvic inflammation and the forma- 
tion of abscesses. 

From this much of the history obtained from the patient's 
mother, I presumed that the cicatrices of the vagina were the prod- 
ucts of the disease of her childhood. 

The treatment employed in this case was such as has been de- 
scribed, and marked improvement has followed. At the end of four 
months after beginning the treatment the vagina admitted Cusco's 
speculum; the tenderness was reduced, but not wholly relieved. 
The patient went to the country for the summer, to return in 
October for futher treatment. 

Scar in the Taginal Wall resulting from an Injury sustained 
during Labor. — I was called to see a lady two months after her con- 
finement with her first child. I learned that she had had a tedious 
labor and was delivered by forceps. She made a good recovery, ex- 
cept that when she undertook to stand or walk she sulfered from 
sharp pains in the vagina and a feeling of dragging and weight, 
especially on the left side. 

On examination I found a recent cicatrix on the left side extend- 
ing from the lower portion of the labium majus up the vagina for 



264 DISEASES OF WOMEN. 

about three in dies. The scar, which was about half an inch in 
width, was quite tender to the touch, and in the center of it, here 
and there, a few granulations remained and bled on being roughly 
touched. The patient, although very healthy and strong, had not 
been able to go up or down stairs or leave the house for two months 
after her confinement, the time when I saw her. 'No other uterine 
or pelvic disease could be found. 

This case shows the trouble which wounds of the vagina, sus- 
tained during confinement, will cause, and it is reasonable to suppose 
that if the parts had been united by sutures at the time of injury a 
more prompt recovery would have followed. 

Scar Tissue between the Posterior Wall of the Cervix Uteri and 
Vagina, caused by Former Treatment. — This lady was fifty years old, 
and had passed the menopause several years. Iler health had been 
very good during most of her life. She had some uterine inflamma- 
tion and leucorrhoea after the birth of her last child, and was treated 
with caustic applications which relieved the leucorrhoea. After this 
she began to have pelvic pain of a neuralgic character, which in- 
creased gradually. This pain was greatly aggravated by exercise. 
The effect of the local suffering and inability to take active exercise 
upon her nervous system was very marked. 

A vaginal examination by the touch detected a thin band of scar 
tissue extending from the posterior wall of the cervix to the vaginal 
wall. The scar was quite tender, and when touched with the probe 
or finger gave rise to the neuralgic pain from which she generally suf- 
fered. The patient was placed on the side, and a Sims's speculum 
introduced. The cervix was caught with a tenaculum and drawn 
forward. This put the scar tissue on the stretch and made it promi- 
nent. The whole scar tissue was removed with one sweep of the 
curved scissors, and the edges of the mucous membrane of the 
vagina were united with a few catgut sutures. The parts healed 
without delay, and all the local pain and general disturbances 
promptly subsided. The relief was so prompt, complete, and per- 
manent, that there can be no doubt about the scar tissue being the 
whole cause of the patient's suffering. 

This case is a fair sample of a class, now fortunately diminish- 
ing in number, in whom scars are produced by the use of caus- 
tics. The general practitioner using a Ferguson speculum and a 
swab in treating diseases of the cervix uteri, usually does very little 
to cure the disease, but much to destroy the tissue of the cervix and 
vagina. The swab charged with a strong caustic solution and 
pushed up into the canal is compressed so that the caustic runs down 



CICATRICES OF THE CERVIX UTERI AND VAGINA. 265 

on the posterior wall of the cervix and vagina. While the diseased 
tissues get very little of the application, the normal tissues at that 
point are destroyed. This is often repeated, and results in forming 
scar tissue such as that presented in this case. Such results of treat- 
ment were often seen years ago, and at the present day they are far 
too common. 

A Band of Scar Tissue just within the Introitus Vaginae, and ex- 
tending across from Side to Side of the Vagina, caused by Forceps De- 
livery. — The patient was undersized, but a strong, healthy lady. 
She was confined with her first child five months before I saw her. 
Iler physician told me that the child was large in proportion to the 
mother, and that he was obliged to deliver with forceps while the 
head was high in the pelvis. In the delivery, much damage was 
done to the cervix and vagina, but the pelvic floor was not torn. 
She recovered slowly from her labor, and continued to have a dis- 
charge and pain, mostly of a neuralgic character. 

I found a semicircular band of scar tissue running from the 
ramus of the pubes, high up and around the vagina to the opposite 
side. The scar was unyielding, so that the finger could be intro- 
duced with some difficulty into the vagina. It extended deep down 
below the mucous membrane of the vagina, and at the upper ends 
was fixed to the pubic bones. It appeared to me that in the original 
injury the whole of the vaginal wall, together with the bulbo-caver- 
nosus muscles and the anterior fibers of the levator-ani muscle had 
been torn away from its attachments to the floor of the pelvis. 

I have never before nor since seen an injury exactly like this, 
and hence I do not know positively how it was produced, but pre- 
sume it occurred as I have stated. About half an inch from the 
median line of the posterior wall of the vagina the scar tissue was 
divided on each side. Traction backward was then made with a 
narrow-bladed Sims's speculum which distended the vulva and at 
the same time brought the ends of the incisions, which were made 
parallel to the axis of the vagina, together. The sides of the incis- 
ions were held together with sutures. The immediate effect of this 
operation was to relieve, in a marked degree, the pains from which 
the patient had suffered. It also restored the dilatability of the 
vulva, so that the patient could resume her sexual duties when the 
incisions had healed. She still has pain and tenderness, and I pre- 
sume that there will be contraction again which will require further 
treatment. 

The case being a recent one, its future history has yet to be de- 
veloped. 



CHAPTER XYL 



INVEESION OF THE UTERUS. 




Inveesiox may be defined as a turning inside out of tlie uterus, 
in which its walls descend into its cavity. The external surface be- 
comes the internal, and the fundus uteri, which should be highest 
^^ in the pelvis, becomes lowest. There are several de- 
grees of inyersion, varying from a mere depression 
of a portion of the "uterus, to a complete inversion. 
In practice two degrees can be made out, and these 
can be easily comprehended by a reference to Figs. 
123 and 124. 

In tlie first form there is a depression of one 
side or partial inversion ; the second form is a com- 
plete inversion. When the vagina is also inverted, 
the condition is known as inversion and prolapsus. 
This complication occurs as a rule in the puer- 
FiG. 123.— Partial P^^al state Only. In all cases of inversion, at least 
inversion (Thorn- at the time when this accident occurs, enlargement 
^^^* and relaxation of the tissues of the nterus are found. 

This is particularly so in the puerperal state, w^hen inversion oc- 
curs most frequently. 

Symptomatology. — The severity of the symptoms depends upon 
the extent of the inversion and the sudden- 
ness with which it occurs. Partial inversion, 
brought about gradually, may not cause sufil- 
cient disturbance to attract attention. The 
symptoms of shock are present when the in- 
version occurs suddenly, as it does in the puer- 
peral state. The shock and pain are more 
marked, as a rule, when the inversion is accom- 
panied with prolapsus. In a few recorded cases, ^ ,„. ^ ,. . 

1 111 ^ c ^ TPi . ^i^- ^24. — Complete in- 

the shock alone proved latal. 11 there is great version (Thomas). 




INVERSIOiT OF THE UTERUS. 267 

hsemorrhage as well as shock, the patient is more likely to suc- 
cumb. 

Hsemorrhage occurs when the inversion is incomplete as well 
as when complete, especially at the time when the accident takes 
place. The presence of the uterus in the vagina causes disturbance 
of the bladder and rectum, by pressure. 

These are the symptoms which occur in acute inversion, and if 
the patient passes safely through this stage then the symptoms of 
chronic inversion appear. 

In complete inversion after the uterus has fully contracted, the 
hsemorrhage is not profuse, except at the menstrual periods, when 
there may be monorrhagia. This is generally a sero-sanguinolent 
discharge for the first week or even later, then the irritation may 
cause congestion, ulceration, and general inflammation of the vagina 
and mucous membrane of the uterus, and a consequent leucorrhoea 
and purulent discharge. 

If the uterus remain outside of the vagina it usually becomes 
dry from exposure to the air, but it also becomes abraded in places 
and finally ulceration occurs. Whether the uterus remain in the 
vagina or becomes completely prolapsed, the inflammation, ulcera- 
tion, haemorrhage, and the purulent discharge which arise there- 
from may break down the general health of the patient and the case 
terminate fatally. 

Throughout all this there is pelvic pain and tenesmus. 

Physical Signs. — The diagnosis (which is not by any means 
easy in all cases) depends largely upon the physical signs. These 
differ somewhat in recent cases and in those of long standing. 
When the inversion occurs after labor, the bimanual touch will 
reveal two very important facts. The uterus is not found in its 
position behind the pubes, but occupies the pelvic cavity, and can 
be outlined in the vagina. By moving the uterus between the 
two hands, the fundus and body will be found below in the true 
pelvis, while in place of the fundus being* found above, a depres- 
sion in the uterus can be felt at the superior strait. If the vagi- 
nal touch alone is relied upon, the condition will be taken for the 
coming placenta. The placenta being attached to the uterus, as it 
usually is at this time, obscures the uterus, but upon trying to re- 
move it from the vagina by hooking down one of its edges with the 
finger, the solid uterus will be found above the placenta, the two 
being united, but easily separated. While this exploration and re- 
moval of the placenta — if it is present — are going on, the left hand 
is placed upon the abdomen, and the absence of the uterus above is 



268 DISEASES OF WOMEN". 

observed, as already stated. Passing the finger above the mass in 
the vagina, in search of the walls of the cervix and the os uteri, a 
furrow is felt which show^s that the walls of the vagina and uterus 
are continuous, and that there is no opening into the cavity of the 
uterus. 

These signs will suffice for any one who is familiar with the 
normal condition of the parts in labor, to make a diagnosis. In 
fact, there are only two things which could easily be mistaken for 
inversion, a fibrous tumor and the presenting membranes in a case 
of twins. The latter could be made out by palpating the abdomen 
and finding the large uterus with the child, and the other, though 
less easily, could be detected by the presence of the uterus behind 
the pubes and the presence of the uterine canal which could be fol- 
lowed by the touch beyond the tumor. 

These physical signs should be sufficient to suggest the diagnosis, 
which can be confirmed by restoring the inversion. 

This is easily accomplished by any one familiar with obstetric 
manipulations. When there is complete prolapsus, as well as inver- 
sion, the diagnosis can be made by inspection. The form of the 
tumor, the appearance of its mucous membrane, the presence of the 
placenta, or, in case that it has been detached, the irregular appearance 
of the placental site compared with the rest of the membrane, and 
the contractions of the uterus, which can be noticed while handling 
the parts, are quite sufficient to settle the diagnosis. 

In old cases, in which the uterus has become reduced to its origi- 
nal size by involution, the diagnosis is not so easy as in recent cases, 
and yet, by the aid of the sound and the bimanual touch, the diag- 
nosis can be made with certainty in the great majority of cases. 

By the touch the round tumor is found projecting into the va- 
gina, and the lips of the os externum can be distinguished surround- 
ing the tumor. The fornices can sometimes be made out also. In 
most of the cases that I have seen the cervix was thinned out so 
that its walls felt as if continuous with the vagina, and the fornices 
were also obliterated. In either condition the evidence is in favor 
of inversion, but when the cervix can be found the evidence is more 
valuable, especially if the finger can be passed up into the cervix 
between its walls and the body of the uterus. There the mucous 
membrane of the cervix can be felt reflected upon the tumor to the 
same extent all around. 

These signs can be made out by the vaginal touch. The biman- 
ual touch is still more satisfactory. By that method the uterus can 
be raised up in the pelvis by the finger or fingers of one hand in the 



INVERSION OF THE UTERUS. 



269 




vagina, while with the other hand a "body with a depression in its 
center can be felt through the wall of the abdomen. Iq spare pa- 
tients with relaxed abdominal muscles the bimanual touch will usu- 
ally suffice to make the diagnosis quite positive. 

In doubtful cases the uterus may be drawn down with a tenacu- 
lum or pressed down by a hand upon the abdomen, while a rectal 
examination with the index-finger of the other hand is made. In 
this way the fingers of the two hands may be made 
to meet above the uterus, and at the same time the 
finger in the rectum may detect the cup-shaped end 
of the uterus above. In case the bimanual touch 
is not practicable, owing to the patient being very 
stout, or the abdominal muscles unyielding, the same 
signs can be obtained by passing a sound into the 
bladder and turning it backward until it meets the 
finger in the rectum above the uterus. 

To facilitate either or both of these methods of 
examination by the touch, the uterus may be drawn 
downward by a noose made of tape or rubber passed 
around the cervix, as recommended by Barnes. 

Chronic inversion is likely to be mistaken for 
fibrous polypus of the uterus. A number of mis- 
takes of this kind are on record, but most of them 
occurred before the time when the uterine sound 
and the bimanual touch were employed for diag- 
nostic purposes. The differentiation can usually be 
made by the methods of examination already de- 
scribed. 

In polypus, the uterine sound can be passed be- 
yond the tumor into the uterus above, whereas, in 
inversion, the progress of the sound is arrested at 
the neck of the uterus. The bimanual touch, rec- 
tal touch, and vesico-rectal examination, reveal the 
uterus above the tumor. The inverted uterus is 
tender, the polypus is not. This sign is of much 
value. By seizing the tumor and turning it around 
it will move in the cervix if it is a polypus. The 
Fig. 126 — Polypus t WO surfaces will p^lide backward and forward upon 

simulating com- i i i • • • . i 

piete inversion each Other, but ni mversion no such motion can be 
(Thomas). produced. Incomplete inversion is not easily diag- 

nosticated under the most favorable circumstances. To distinguish 
partial inversion from an intra-uterine fibroid of small size is next to 



Fig. 125. — Polypus 
simulating partial 
inversion (Thom- 
as). 




270 DISEASES OF WOMEN. 

impossible. Fortunately, sueli a diagnosis is not imperative, because 
active treatment is not often called for in these incom]3lete and 
doubtful cases. 

Prognosis. — Inversion is always a grave condition. If it does 
not prove fatal at first from shock and haemorrhage, it becomes a 
continuous trouble, which either gradually undermines the general 
health, and thereby shortens life, or else keeps the subject in a state 
of impaired usefulness and ill health. There is no certain tendency 
to natural recovery, and although quite a number of cases have been 
recorded in which spontaneous replacement of the uterus was said to 
have taken place, such an occurrence must be very rare. From the 
fact that most of these cases are recorded by the older authors, it is 
possible that in some of them the diagnosis was incorrect. One thing 
is certain, no such fortunate termination should be expected or rehed 
upon. Without treatment the condition will probably continue. 

The prognosis is rendered more grave by the fact that tho 
treatment is not without danger. 

There are several methods of treating inversion, but neither of 
them is wholly safe. This statement applies to chronic inversion. 
When the inversion occurs during labor, immediate replacement is 
easy and not attended wdth any great risk. The dangers in restor- 
ing an old inversion are from inflammation and septicaemia, pro- 
duced by the injuries to the uterus, vagina, and adjoining parts 
daring the violent efforts necessary to accomplish the object. These 
dangers are greatly increased by unskillful operating, still unfortunate 
results have occurred in the practice of the most skillful surgeons. 

Causation. — The conditions which predispose to inversion are 
enlargement of the uterus and relaxation of its tissues. These are 
best illustrated in the puerperal state. Inversion can not take place 
in a normal non-puerperal uterus. The condition of the uterus im- 
mediately after the delivery of the child is most favorable to the 
accident, and it is at this time and under these circumstances that 
inversion most frequently occurs. 

Predisposing causes, other than pregnancy or parturition, are 
known, but they are operative in bringing about a condition of en- 
largement of the uterus and relaxation of its tissues. These are 
distention of the uterus from tumors or fluids. The relaxation of 
tissues which is found in imperfect involution and prolapsus is also 
given as a predisposing cause, but I have not seen the record of any 
case which could be clearly traced to this cause. 

To briefly restate this matter, the tendencies to inversion depend 
upon enlargement, distention, and relaxation. The exciting causes 



INVERSION" OF THE UTERUS. 271 

are traction or pressure upon the fundus uteri when it is in a con- 
dition favorable to inversion. The direct causes are traction upon 
the umbilical cord or pressure upon the fundus uteri at the moment 
when the child is expelled, or sudden delivery of the child, either 
bj traction or the natural muscular efforts. Muscular efforts, when 
there is relaxation of the uterus, are mentioned as a cause, and cases 
are recorded in which inversion is said to have occurred in that way, 
but that cause must be seldom operative. Prolapsus uteri is also 
credited with having some causative relation to inversion, but I 
have no knowledge on this subject. J^ext to parturition come intra- 
uterine tumors in the causation of inversion. All the cases which 
have come directly under my own observation, or that have come to 
my knowledge indirectly through competent contemporary authori- 
ties, have been clearly traceable to parturition or fibrous polypi. 

The conditions are alike in pregnancy and intra-uterine tumors, 
so far as the uterus is concerned in the predisposition to inversion. 
There is enlargement of the uterus with relaxation followed by 
muscular contraction. During the growth of the tumor the uterus 
increases in size, and finally endeavors to expel the growth, and 
when the muscular contractions are going on the fundus uteri is 
dragged downward by the pedicle of the tumor. In this way all 
the predisposing and mechanical conditions are present which are 
most competent to cause inversion. 

Treatment. — There are several methods of managing inversion. 
Of course the indications are to restore the uterus to its proper rela- 
tions. This is often difficult in chronic inversion, and sometimes 
impossible, hence other means must be employed to give all relief 
possible. 

In case replacement can not be accomplished, the most promi- 
nent symptoms should be relieved by treatment ; haemorrhage should 
be controlled by astringents and inflammation should be reduced by 
appropriate care. Inversion can be successfully treated if seen im- 
mediately after it occurs. The method of operating is to grasp the 
uterus in the right hand, and carry it upward until the cervix can 
be felt with the left hand through the abdominal wall ; counter- 
pressure is then made while the fundus uteri is being forced upward 
with the right hand in the vagina. The abdominal walls being thor- 
oughly relaxed, as they are immediately after conflnement, the bi- 
manual manipulations are comparatively easy. The os uteri can be 
felt with the left hand, and by pressing the abdominal wall down 
into it with the Angers it is dilated, and when the fundus is restored 
far enough to engage in the os, the lips of the cervix can be pushed 



272 DISEASES OF WOMEN". 

over the fundus, in the same way that they are pushed over the head 
of the child in delivery. 

Cases of Recent Inversion. — I have seen four cases of inversion 
soon after they occurred, one in my own practice and thi-ee in con- 
sultation. 

Two of these were inversion with complete prolapsus, and the 
other two were uncomplicated. My own case was that of a strong 
young woman in her second confinement. The pelvic outlet was 
rather narrow, and the perinseum rigid, so that the pains which ex- 
pelled the head were most powerful, especially the last one. The 
moment that the head passed the perineum the whole child was 
expelled with extraordinary force. "While the nurse rested her hand 
upon the abdomen I tied the cord, and then I found the placenta 
presenting at the vulva. I passed my finger up to bring the edge 
down and then deliver it, but I found a hard body above to which it 
was attached. I then passed my left hand over the abdomen, and 
found that the uterus was not there. Inversion was suspected, and 
I at once separated and removed the placenta, which was very easily 
done in this case, and then with bimanual manipulation restored the 
uterus with the greatest facility. The removal of the placenta and 
the reduction of the uterus occupied but a moment. The patient did 
not apparently suffer, but I think that there was slight shock and 
consequent ansesthesia, so that the reduction was painless and finished 
before she reacted. 

I found I could grasp the fundus easily, and by making firm press- 
ure upon one comer with my thumb and upon the other with the 
middle finger, and thus raising the whole uterus up until I could feel 
the OS with the fingers of the left hand, the pressure and counter- 
pressure effected the reduction with ease and rapidity. 

I found that the reduction of one horn first, as recommended by 
Dr. Noeggerath, answered well, first because the horn was more 
easily brought under pressure, and also because it appeared to yield 
most readily. In grasping the uterus the thumb naturally rests 
upon one horn, and by making firm pressure at that part, which is 
more convenient than to press upon the center of the fimdus, it 
appears to be the natural way of effecting reduction by the unaided 
hand. The hand was made to follow up the reduction, so that when 
it was completed the hand was fully within the uterus, and it was left 
there, and pressure upon the uterus with the left hand upon the 
abdomen was made until the uterus contracted and the hand was 
expelled. This was the part of the procedure which required the 
most time, owing to the uterus being slow to contract. 



INVERSION OF THE UTERUS. 273 

The three other cases were seen in the practice of others. One 
that I saw with Dr. A. R. Matheson, was a complete prolapsus as 
well as inversion. I saw the patient in about half an hour after the 
inversion occurred. There was considerable shock, and the doctor 
was obliged to hold the uterus with the placenta attached in the firm, 
grasp of both hands to prevent haemorrhage. The prolapsus was 
reduced first and then the inversion, in the same waj and in about 
the same time as the case just described. I saw another case of in- 
version and prolapsus with Dr. Bliss. It was of three days' stand- 
ing. The doctor did not attend in confinement, but was called to 
see the patient because of the inversion. When I saw her she was 
exceedingly weak. The pulse 140, and feeble. She was anaemic, 
and the abdomen greatly distended and tender to the touch. The 
uterus was resting between the limbs, and parts of the mucous mem- 
brane here and there were in a sloughing condition, and other por- 
tions were dry and glazed looking. Vaseline was applied over the 
whole surface, and the uterus first pushed up into the vagina and 
then grasped with the hand, and the inversion reduced. The opera- 
tion in this case was more difiicult and prolonged. Owing to the 
tympanitic state of the abdomen it was difiicult to make proper 
pressure upon the lips of the cervix, and that was a cause of delay. 
The extreme depression of the patient (while it raised a doubt as to 
her being able to stand the operation of reduction) gave that com- 
plete relaxation and general anaesthesia which was favorable. No 
anaesthetic was given. In about ten minutes the reduction was 
effected. The patient recovered. 

One other case I saw with Dr. Bodkin. The inversion occurred 
at two o'clock, and three hours later it was reduced. There was 
some excitement of the pulse, and the patient had pelvic pain. 
There was very little haemorrhage, but there had been considerable 
at the confinement. Chloroform was administered, and the reduc- 
tion was accomplished by the same method. More time was required 
than in either of the other cases, because there was more contraction 
of the uterus, but by means of upward pressure and counter-pressure 
upon the lips of the cervix the reduction was accomplished in a short 
time. 

Chronic inversion is far more difficult to manage than recent in- 
version. In fact, when the inversion has existed long enough to 
permit the uterus to regain its original size, or nearly so, by involu- 
tion, and has contracted firmly, its reduction is always difficult, and 
sometimes impossible. This has led surgeons to devise seveml 
methods of reducing this inversion under these circumstances. 
19 



274 DISEASES OF TVOMEN". 

Dr. Thomas has classified these methods as follows : Methods 
of effecting gradual reduction and methods of effecting rapid reduc- 
tion. The method of reduction by taxis is the oldest and most re- 
liable, and should be tried first in all cases, because, if it fails, the 
gradual reduction may be tried subsequently, providing that the 
taxis is not so violent and prolonged as to cause fatal inflammation. 

There are several ways of applying taxis, but only two ways of 
attaining the desired end. The principle of the one is to reduce 
first that portion which was last inverted, and the other is to reduce 
the fundus first and dilate the cervix at the same time, so that the 
portion first inverted is first reduced. To some extent both objects 
may be attained at the same time by so manipulating that both 
changes of position may go on together. The method of operating 
is as follows : The patient should be placed upon the operating 
table in the dorsal position, and the surgeon's liand carefully in- 
troduced into the vagina. It is necessary to dilate the vagina, in 
the great majority of cases, in order to admit the hand. Some- 
times the dilatation is difficult to accomplish with the hand without 
rupturing the vagina. "When this is the case, dilatation as a pre- 
liminary measure should be accomphshed by stretching with the 
speculum and the inflatable rubber bag. The right hand is introduced 
into the vagina and the uterus grasped with the thumb and fingers. 
The uterus is compressed and at the same time carried upward, and 
held against the left hand, which makes the counter-pressure. The 
manipulations with the right hand should be so directed that one or 
both horns should be reduced first. The cervix should be dilated, 
and reduction begun at that point at the same time that reduction 
of the horn is effected. Fortunately, the efforts to accomplish the 
one favor the other. 

This method of E'oeggerath's, which has already been discussed, 
is that whicli I prefer, but there are certain modifications which are 
of value in certain cases, and should be employed when failure of 
the one method makes the trial of the modified methods necessary. 
For example, Dr. Thomas has employed a cone of wood in place of 
the left hand for dilating the cer\dx. In thin patients this can be 
inserted into the ring of the cervix, which can be felt through the 
abdominal walls, and gradually forced into the cervix until sufficient 
dilatation is obtained. Barren placed the fingers around the body of 
the uterus and the thumb upon the fundus, and forced the cervix 
against the sacrum to secure counter-pressure. 

Courty's method consists in using the index and middle fingers 
of the left hand in the rectum, to dilate the cervix and make coun- 



INVERSION OF THE UTERUS. 275 

ter-pressure. This method of using the left hand combined with 
the method of Dr. Noeggerath is highly commended by Dr. T. G. 
Thomas. Dr. Emmet describes his method as follows : " In 18 65 I 
succeeded in effecting a reduction by passing my hand into the va- 
gina, and, with the fingers and thumb encircling the portion of the 
body close to the seat of inversion, the fundus was allowed to rest 
in the palm of the hand. This portion of the body was firmly 
grasped, pushed upward, and the fingers w^ere then immediately 
separated to their utmost ; at the same time the other hand was em- 
ployed over the abdomen in the attempt to roll out the part form- 
ing the ring, by sliding the abdominal parietes over its edge. This 
manoeuvre was repeated and continued. At length, as the trans- 
verse diameter of the uterine cervix and os w^as increased by lateral 
dilatation with the outspread fingers, the long diameter of the body 
became shortened, and the degree of inversion proportionately less- 
ened. After the body had advanced well within the cervix, steady 
upward pressure upon the fundus was applied by the tips of all the 
fingers brought together." 

This method, w^hich appears to me like Yandel's, is natural in 
theory, but in trying it I have found that I could not separate the 
fingers to any extent, owing to the fact that the extensor muscles are 
feeble in their action, and not capable of doing more than resisting 
the pressure of the vagina. 

Dr. Emmet also commends the closure of the cervix with silver 
sutures in cases w^here the reduction can not be completed. He 
gives a diagram representing the cervix as being about three times 
as long as the body, and drawn over the fundus and held there by 
sutures. I have never practiced this treatment for the reason that 
in all the cases in which I have been able to get the body and fun- 
dus reduced wholly within the cervix, the complete reduction has 
been easily and speedily accomplished. Again, I can not see how 
sutures of any kind would resist the pressure of a partially inverted 
uterus, with a strong tendency, which there always is, to become 
further inverted. 

depositors have been used to aid in the taxis by De Paul, Avel- 
ing, White, and others. The most useful of these, and one that 
fulfills the requirements is that invented by Dr. John Byrne, of 
Brooklyn. It consists of a cup and stem with a movable plug or 
button in its center. The button forms the bottom of the cup when 
it is placed over the uterus, and while the cup is in place the pluo* 
is pushed forward by the screw in the handle against the fundus, 
and in that way makes the required upward pressure. 



276 



DISEASES OF WOMEN". 




Fig. 12*7. — Byrne's method of reduction. 



Fig, 127 shows Dr. 
Byrne's repositor as used, 
and its cup or bell-shaped 
instrument with the plug 
and screw adjustment for 
making counter - pressure 
and dilatation of the cervix. 
A piston in the lower cup 
pushes the fundus up. 
There are a number of ad- 
justable cups which can be 
adapted to the require- 
ments of different cases. 

Cases are sometimes met 
which can not be restored 
by taxis. Resort must then 
be had to such means as 
gradual reduction by con- 
tinuous pressure. This is 
effected by a cup and stem 
(Fig. 128) which are held in place by a perineal band of rubber or 
elastic fastened to a bandage applied around the pelvis. When using 
this instrument care 
must be taken to 
keep the uterus in 
the Hue of press- 
ure. When the va- 
gina is relaxed the 
uterus may fall 
backward or for- 
ward out of the 
line of pressure ; 
this can be avoided 
by using a tampon 
around the uterus, 
which may be worn 
for two days if no 
great distress is 
caused by it. It 
should be examined 
from time to time, 

and if there is much Fig. 128.— Cup pessary to exercise gradual pressure (Thomas) 




INVERSION OF THE UTERUS. 277 

irritation the instrument should be removed and vaginal injections 
used until relief is obtained, and the use of the instrument may be 
again resumed. 

The rubber bag filled with water answers a very good purpose. 
To apply this, the patient should be placed in Sims's position, and 
through the speculum, the upper portion of the space between the 
uterus and vagina should be filled w^ith prepared wool ; then the bag 
should be introduced between the fundus uteri and the pelvic fioor, 
and distended with water. A firm perineal band is then used to 
support the pelvic floor. Dr. Thomas recommends a strip of adhe- 
sive plaster for the perineal band, one end being fastened to the 
sacrum and the other to the abdomen, with two openings, one for 
the tube of the bag, and the other opposite the urethra to permit 
urination. I prefer the ordinary muslin or elastic band, because it 
is more easily removed and readjusted. The degree of pressure and 
the time wliich it should be continued must depend upon the re- 
sults. 

If there is much pain or irritation the treatment must be sus- 
pended. The combination of elastic pressure and taxis has been 
employed with advantage. After the pressure has been used for a 
time taxis should be tried, and in case this fails the elastic pressure 
should be again attempted. Care must be exercised in the use of 
taxis — it should not be too violent or long-continued ; this must be de- 
cided by the operator in each case. 

Dr. Charles Martin, of France, succeeded by using a stream of 
cold water projected against the fundus uteri, through the speculum. 
This he employed twice a day. The stream was thrown with con- 
siderable force; he also filled the speculum with cold water, and 
kept the uterus in it three or four minutes. Dr. T. G. Thomas, 
from whose work I take the above statement, approves of this 
method. 

Dr. Thomas has devised another method, which I understand 
he employs or advises where other methods fail. The following is 
taken from his work on diseases of women : " Thomas's method 
consists in abdominal section over the cervical ring, dilatation with 
a steel instrument, made like a glove-stretcher, and reposition of the 
inverted uterus by any one of the methods mentioned, by the hand 
in the vagina. Fig. 129 will render this clear. 

" This procedure, let it be remembered, is not offered as a method 
of treating inversion of the uterus, but as a substitute for amputa- 
tion. Few cases will, I think, resist elastic pressure and judicious 
taxis ; but that some will do so can not be questioned. It is to 



278 



DISEASES OF WOMEN. 



save these few cases from amputation that I suggest abdomiual 
section. 

" One of the cases operated on in this way has proved fatal. Let 
it not be forgotten that a certain number of these cases treated by 
elastic pressure and by taxis likewise do so, for, as in my second 
case, these operations are often performed upon exsanguinated 
women whose blood is impoverished. One instance of death after 
reduction by elastic pressure is recorded by Dr. Tait in the eleventh 
volume of the ' London Obstetrical Transactions,' while one of the 

earliest cases on record 
reduced by taxis — that of 
Dr. White, of Buffalo, 
likewise ended fatally." 

One other method is 
worthy of mention, name- 
ly, that of Dr. Brown, of 
Baltimore. He makes a 
free incision in the fun- 
dus uteri, and through the 
opening thus made he 
stretches the cervix and 
then reduces by taxis. In 
ease of failure of all ef- 
forts, hysterectomy may 
be performed. This, I 
consider advisable, if the 
patient is near to or past the menopause, but it should not be un- 
dertaken until all other methods have failed. 

There are several methods of amputating the inverted uterus. 
Dr. McClintock applied a string ligature around the highest portion 
which strangulated the uterus, and in two or three days when de- 
composition of the tissues began, he amputated. Hegar accom- 
plished the same object by passing strong sutures through the cer- 
vix, and after drawing them tight enough to close the vessels and 
close the peritoneal cavity, the body was amputated. 

It will suffice to simply mention amputation without giving elab- 
orate details. It was frequently practiced in the past, but is sel- 
dom heard of now. Other methods succeed, and with the method 
of Thomas in reserve — in case pressure and taxis fail — amputation 
will seldom, if ever be called for. Cases might be quoted to illus- 
trate the treatment of chronic inversion, but they would add noth- 
ing of value to the methods of operating given above. 




Fig. 129. — Replacement of uterus by dilatation 
through abdomen. (Thomas.) 



CHAPTEE XYII. 

DISLOCATIONS OF THE UTEEUS. 

The uterus is peculiarly subject to physiological changes of 
position. The bladder in front causes the uterus to move forward 
and backward according to its dilatations and contractions. In a 
similar but much less extensive way, distention of the rectum acts 
to push the uterus forward. The abdominal pressure from above is 
constantly changing, and is, therefore, constantly affecting the posi- 
tion of the uterus less or more. The movements of the uterus 
under the influence of the ever varying degrees of abdominal press- 
ure are easily observed by watching the anterior vaginal wall and 
uterus through a Sims's speculum in the living subject. There is 
an up and down motion, very limited but constant, caused by ordi- 
nary respiration, and under extra exertion, such as coughing, the 
displacement becomes very marked. 

Below there is the pelvic floor, which has least of all to do with 
changing the position of the uterus, and yet much to do in counter- 
acting the inclinations to displacement produced by other influ- 
ences. 

These changes of position, when limited in degree, are physio- 
logical, the organ promptly returning to its original position as soon 
as the displacing influence is removed. It is only when the uterus 
remains displaced permanently or is carried far beyond the physio- 
logical limits that the dislocation is to be regarded as pathological. 
When this occurs, the malposition gives rise to suffering from de- 
ranged menstruation, circulation, and innervation, and in some cases 
to sterility. Usually, the functions of the bladder and rectum are 
disturbed and the general system suffers from reflex influences. It 
is only when such symptoms as these are present that displacements 
of the uterus claim the attention of the gynecologist. 

In order to fully comprehend displacements of the uterus it is 
very necessary that the normal position of the uterus should be 



280 



DISEASES OF WOMEN. 



clearly understood, and this can only be attained by a knowledge of 
the anatomy of the pelvic organs. 

Anatomy. — In discussing this subject attention will be chiefly 
directed to the position of the uterus in the pelvis, its relations to 
neighboring organs, and the position and character of the structures 
which keep it in position. 

One would naturally turn to the cadaver in the hope that by 
careful dissection the exact position of the uterus could be deter- 
mined, but after life is extinct the 
uterine supports lose their firm- 
ness, and changes of position usu- 
ally take place. Moreover, it fre- 
quently happens that the pelvic or- 
gans are less or more displaced 
toward the end of life, so that a 
normal state of the parts is not 
often found in the cadaver. Dis- 
section also tends to displacement, 
no matter how carefully it may be 
performed. To obviate this, sec- 
tions of the frozen subject have 
been made, and much valuable in- 
formation obtained from them. 
Still, the greater part of useful in- 
formation on this subject must be 
obtained from careful and oft-repeated examinations of the living 
subject. With information obtained from all these sources there are 
still differences of opinion among authors on certain points. 

Under the circumstances, in place of giving a number of conflict- 
ing opinions, it will be better to give the views which I have 
adopted as the result of my own observations on the living subject, 
and after a careful investigation of the views of others. 

In the first place, it may be said that the uterus is wholly within 
the true pelvis. 

The line on the diagram running between the symphysis pubis 
and the promontory of the sacrum divides the true pelvis from the 
abdomen, and all the pelvic organs, the uterus included, are below this 
plane, the superior strait, as the obstetricians call it (Fig. 64). The 
long diameter of the uterus in the pelvis corresponds very nearly to 
the axis of this plane, as represented by the line (Fig. 130), and it is 
equidistant from the sides of the pelvis. 

The position of the uterus varies from time to time, as already 




Fig. 130. — Section of pelvis, showing its 
inclination and the axis of the inlet. 



DISLOCATIONS OF THE UTERUS. 



281 



stated, but in all its changes it returns to the axis of the inlet of the 
pehds, slightly behind the center of the true conjugate. This is not 
mathematicallv correct, but is sufficiently so to form a basis from 
which further studies, both anatomical and clinical, may be con- 
ducted. 

In order to obtain some idea of the position of the uterus and the 
influences which the other pelvic organs have in changing this posi- 
tion, reference should be made to Fig. 64, which shows a section of 
the normal pelvis. Fig. 131 shows the changes in the position of 




Fig. 131. — The normal range of the uterine axis, varying according to the distention of 
the bladder ; a, with bladder empty ; d, with bladder full (Van der Warker). 

the uterus during the several degrees of distention of the bladder. 
These physiological changes should be noted and the causes which 
give rise to them, in order that they may be recognized clinically. 
Next in the order of inquiry are the anatomical structures by whicli 
the uterus is held in position. This requires a consideration of the 



282 DISEASES OF WOMEN". 

structural associations of the uterus and all the other pelvic organs 
and tissues. The position of the several pelvic organs may be 
given in a general way as follows : The uterus in the center, Fallo- 
pian tubes and ovaries on either side, the bladder in front, rectum 
behind, and the vagina below. Covering all of these, except the 
vagina, is the peritonaeum, which is the chief bond of union be- 
tween the upper portions of the pelvic organs, and out of which 
are formed the ligaments which have much to do in keeping the 
uterus in place. The peritonseum, while it covers the pelvic organs, 
is attached to the bony walls of the pelvis through the medium 
of the periosteum and areolar tissue, so that one end of each liga- 
ment may be said to have an attachment to the inner side of the 
pelvic bones. The round ligaments are anatomically an exception 
to this rule. They contain muscular tissue in considerable quan- 
tity, and are really outgrowths from the uterus in the form of 
round cords, which start from the uterus near the proximate ends of 
the Fallopian tubes, and sweeping round the outside of the pelvis, 
pass out through the inguinal rings into the labia majora. These 
ligaments, as well as all the others, can be seen by looking down 
upon the pelvic organs in situ. The uterus is seen in the middle of 
the pelvis, and extending across on either side of it are the two 
broad ligaments made up of the two folds of peritonaeum, which 

unite after covering the uterus. 
Running backward from the uterus 
to the sacrum are those peritoneal 
folds known as the utero-sacral liga- 
ments. Between the uterus and the 
bladder, on the sides of the latter, the 
folds of peritonaeum form the utero- 
vesical ligaments. These ligaments 
Fig. 132.— Diagram of the uterine liga- are SO Called, not because they are 

ments as seen on looking into ttie brim. i i> t - .• i - 

° composed oi hgamentous tissue, but 

rather because they perform a function similar to that of hgaments. 
With the exception of the round ligaments which are composed of 
muscular tissue covered with peritonaeum, the others are made up 
of double folds of peritonaeum containing between these folds are- 
olar tissue and some fibers of the pelvic fascia. 

An idea of the position of these ligaments and their relations to 
the uterus may be obtained from Fig. 132. 

I have noticed that, in the dissecting-room, gentlemen are not 
able at all times to find the utero-sacral and utero-vesical ligaments ,* 
the broad and round ligaments they easily note. The others can be 




DISLOCATIONS OF THE UTERUS. 283 

brouglit into view in the following manner : If the uterus be drawn 
well forward by a tenaculum, two tense bands will be seen, the utero- 
sacral ligaments, extending from the side of the uterus back to the 
sacrum, and as thej are thus raised up a pouch of peritonaeum ap- 
pears between them. This is the sac of Douglas. By reversing 
this manipulation, and drawing the uterus backward, the utero- 
vesical ligaments will be seen running forward on either side of the 
bladder. 

The utero-vesical ligaments, in addition to their attachments to 
the uterus and bony walls of the pelvis, are also connected indirect- 
ly to the anterior vaginal wall by intervening areolar tissue. The 
utero-sacral are connected in the same indirect way with the upper 
portion of the posterior vaginal wall, and also to the rectum, on the 
left side at least. 

At the junction of the supra- vaginal portion of the cervix and 
body of the uterus all the ligaments, except the round ones, are 
attached. Here also the anterior and posterior vaginal wall and a 
portion of the bladder join these other structures. 

The union of these structures at this point is not direct, but is 
through the intervention of areolar tissue which is found in con- 
siderable quantity in this region. From this it will be seen that 
these ligaments are continuous from side to side, and also from be- 
fore backward. 

The chief function of these ligaments, aided by the anterior 
vaginal wall, is to keep the uterus and bladder in position. This 
is clearly evident from the mechanical principle apparent in the 
anatomical arrangement of the parts in question, and from the fact 
that the uterus remains in place for a considerable time when the 
pelvic floor is defective, and the abdominal pressure more marked 
than normal. 

In short, many cases have been seen clinically in which all the 
other means that could possibly contribute to supporting the uterus 
were removed by disease and injuries, and yet the uterus was main- 
tained in position under ordinary circumstances. The most rational 
idea of the means and ways by which the uterus is maintained in 
the pelvis I obtained from the following statement by Dr. Frank P. 
Foster. Speaking of the supports of the uterus, he says : " Ordi- 
narily, they consist wholly of the anterior wall of the vagina in 
front, and the utero-sacral ligaments behind, which together con- 
stitute what may be called a beam traversing the pelvis antero- 
posteriorly on which the uterus rests, being interposed between 
them, firmly attached to the one anteriorly and to the other poste- 



284 



DISEASES OF WOMEX. 



riorlj, making them, so far as mec-lianical effect is concerned, one 
structm-e." This is a clear and comprehensive statement of the prin- 
ciples npon which the ntero-sacral ligaments and the anterior vagi- 
nal wall act in supporting the uterus. I would go one step further 
than Dr. Foster, however, and claim a hke function for the other 
uterine ligaments. The broad ligaments, firmly attached to the bony 

walls of the pelvis, and holding 
the uterus in their folds, make 
a continuous structure extend- 
ing across the pelvis in its 
transverse diameter. 

These structures, taken to- 
gether, act hke " beams" or (to 
be more mechanically accurate) 
cables of a suspension-bridge, 
which support to a large ex- 
tent the uterus in its center. 
The utero - vesical ligaments 
also supplement the anterior 
vaginal wall as a supporting 
medium. According to this 
view of the subject, the chief 
supports of the uterus are the 
vesico-uterine, and broad liga- 




FiG. 133. — Section of pelvis with the sliags of 
the uterus ; behind, the utero-sacral liga- 
ments ; in front, the anterior vaginal wall 
(after a section by Hart). 



anterior vaginal wall, utero-sacral 
ments. 

Fig. 133 shows a section of the pelvis with these ligaments and 
the anterior vaginal wall with the uterus restiag upon them. 

Fig. 134 shows a transverse 
section of the pelvis just in 
front of the uterus and broad 
ligaments, and represents these 
structures and the manner in 
which they support the uterus. 

A similar function may be 
claimed for the round liga- 
ments, at least so far as their 
effect in preventing the back- 
ward displacement of the uter- 
us. Some have claimed that 
the round ligaments have but 

little supporting power to sustain the uterus in place, while oth- 
ers give it much credit in this direction. Those who believe in 




Fig. 134.- 



Diagram of the uterus slung between 
the broad lio:aments. 



DISLOCATIONS OF THE UTERUS. 



285 



Alexander's operation of shortening the round ligaments for the 
relief of retroversion of the uterus certainly claim great supporting 
power for these ligaments, and with good reason, I think. 

Finally, I may add, that I believe that the ligaments, the vagina, 
and the other pelvic organs all aid in keeping the uterus in position, 
and are sufficient to do so under ordinary circumstances. Still, when 
extraordinary strain is brought to bear upon the pelvic organs, the 
pelvic floor supplements these supporting structures. Moreover, the 
relation of the trunk to the pelvis has much to do, if not in keeping 
the pelvic organs in place, certainly in freeing them from pressure 
from above. 

The pelvis is so placed that, in the erect posture, its cavity is be- 
hind rather than beneath the abdomen, and the abdominal muscles 
partially divide the greater cavity 
from the lesser. This is shown in 
the accompanying diagram, where 
the arrow indicates the direction of 
the force transmitted to the pelvis 
through pressure from above (Fig. 
135). 

There is very little direct ab- 
dominal pressure upon the pelvic 
organs in the erect posture. The 
axis of the pelvis is backward and 
downward, while that of the ab- 
domen is perpendicular, so that the 
pressure is indirect from above. 

Some claim that a suction power 
is exerted upon the pelvic contents 
by the diaphragm. It is said to 
act like a piston in the cylinder of 
a pump. There is reason to be- 
lieve there is something in this, 
from the fact that, on examination 

through a Sims's speculum, the uterus is seen to rise and fall with 
respiration. This motion is to a large extent arrested when the pa- 
tient is in the erect posture. 

If it is a fact, as it appears to be, that the abdominal organs ai-e 
fixed by suspension in their normal position, and that in their descent 
during this limited motion the pressure upon the pelvic organs is 
indirect, then this relationship contributes to maintain the position 
of the pelvic organs as surely as if there were some traction or suc- 




135. — The normal inclination of the 
pelvis and the transmission of force 
from above. 



286 DISEASES OF WOMEK 

tion action of the diaphragm tending to draw these organs up- 
ward. 

In regard to the pelvic floor and its relations to the displacements 
of the nterus, that subject has been fully discussed under the head 
of injuries of the pelvic floor. It is only necessary to repeat my 
behef already expressed to the effect that, while the pelvic floor does 
not directly support the uterus, it indirectly aids in doing so, and if 
it is lost from injury prolapsus of the pelvic organs follows as a rule. 



DISPLACEMENTS OF THE UTERUS. 

There are a great many forms of displacement of the uterus, if 
every change of position of that organ be taken into account, but of 
those that occur as primary affections there are only two that are 
often seen, and one that is very rare. These are downward, back- 
ward, and forward — that is, prolapsus, retroversion, and antever- 
sion. 

Prolapsus and retroversion are really the only forms of displace- 
ment which practically claim attention in this connection. These 
the gynecologist is called upon to treat daily as primary affections. 
Occasionally, a case of anteversion may be seen which apparently is 
not caused by some other affection more important than the conse- 
quent displacement, but this is exceedingly rare. Again the uterus 
may be anteverted to a considerable extent without causing the 
slightest trouble. This foi-m of displacement (quite a rare one) is 
generally produced as a consequence of some other disease, either of 
the uterus itself or the organs and tissues around it, or else when it 
does occur it gives no trouble ; and, as a rule, very little can be done 
to relieve it by the ordinary methods of treating uncomplicated dis- 
placements. Taking all this into account, it is evident that the 
downward and backward displacements alone demand special atten- 
tion, either in practice or in the discussion of the subject. 

The other forms of disj^lacement of the uterus, described in text- 
books, are the right and left lateral anteversions and retroversions. 
These displacements are always due either to some lesion of develop- 
ment or to some previous affection, the products of which either 
push or pull the uterus out of place. There is also a retrocession 
of the uterus and an antecession, which are not described in books. 
Perhaps better names for these would be transposition backward or 
forward. In these dislocations the uterus is found either behind or 
in front of the axis of the pelvic cavity, or superior strait. These, 
like the lateral dislocations, are secondary to some abnormal state 



DISLOCATIONS OF THE UTERUS. 



287 



which caused them, and lience they are to be looked upon as signs 
and consequences of the primary disease. 

By adopting this classification it simplifies the subject very 
much, and leaves one free to give attention to the downward and 
backward dislocations and their pathology, diagnosis, causation, and 
treatment. Again, the two forms of displacement in question are 
the only conditions of malposition that can be directly treated with 
favorable results. In the other forms, such as lateral versions, treat- 
ment must be employed to remove the morbid states which push or 
pull the uterus out of place, and therefore, the discussion of such 
displacements should be confined to the diseases which cause them. 



PROLAPSUS OF THE UTERUS. 

This is a downward displacement of the uterus commonly called 
falling. It is of necessity always associated with displacement of the 
other pelvic organs and 
tissues, to a greater or less 
extent, according to the 
degree of descent of the 
uterus. 

There are several de- 
grees of prolapsus uteri 
which have been various- 
ly described. While au- 
thors designate the most 
important stages of de- 
scent by degrees, it should 
be understood that practi. 
cally there is no line of 
demarkation between the 
degrees. According to 
this arrangement, when 
the uterus sinks so that 
the cervix rests entirely 
on the pelvic floor, it is 
named prolapsus of the first degree ; when the uterine axis has be- 
come vertical or coincides with the axis of the outlet, the cervix ap- 
pearing at the vulva, the second degree is present ; while in the 
third degree the organ is partly or wholly outside the introitus. 
Fig. 136 shows the three degrees, and may convey a clearer idea 
than further description. 




Fig. 136.— The three degrees of prolapsus. The upper 
outline is a little above the normal position. 



288 DISEASES OF WOMEN". 

Bj some aothorities all the degrees of prolapsus in which the 
■uterus still remains within the vulva are termed incomplete, while 
those in which it protrudes partially or completely beyond the vulva 
are called complete 

This latter arrangement of the subject is perhaps as easily com- 
prehended and as useful in practice as any other. The complete 
degree is often spoken of as procidentia. 

Pathology. — Prolapsus of the uterus takes place slowly, as a rule. 
Sudden prolapsus may possibly occur, but it must be a rare thing, ex- 
cept in the first degree. In the few cases that I have had an oppor- 
tunity of watching from beginning to completion, the displacement 
has been gradual. At first the uterus descended to the first degree 
of prolapsus, and then to the second, and finally to the third or com- 
plete stage. The time occupied in making the complete descent 
varies from months to years. The changes which take place in the 
supports of the uterus and the other pelvic organs during the pro- 
gressive development of the prolapsus are usually the same in all 
cases with few exceptions, but the order in which they appear differs 
according to the cause of the descent. This again depends upon the 
point in the structures at which the lesions begin to develop. 
There are three methods of development of prolapsus. In the first, 
the uterns begins to descend because it is too heavy and makes too 
great demands upon its immediate supports, or else these supports 
become defective from pathological changes. This is a descent of 
the uterus from loss of direct support. The second order of descent 
is by loss of the pelvic floor, which permits the vagina, bladderj and 
part of the rectum to descend, and then the uterus follows. The 
third in order is made up of the two others, the first and the second, 
all the conditions mentioned in those being operative at the same 
time. 

The changes in the supports are elongation from imperfect in- 
volution after parturition, or stretching produced by enlargement of 
the uterus, or pressure on it from above by long standing, stooping, 
or lifting. In the former condition the supports are too long ; in 
the latter they are attenuated as well as elongated. In both states 
the upper portion of the vagina is distended and the bladder slightly 
prolapsed or drawn backward. There is also, in some cases, loss of 
the areolar tissue, and the pelvic fascia has lost its strength of fiber. 
This traction upon the rectum, bladder, and the blood-vessels is pre- 
sumed to interrupt the return circulatioUo Whether that is a fact as 
regards the causation or not, there is usually a passive hypereemia 
of the parts in these displacements. These changes of the positioii 



DISLOCATIONS OF THE UTERUS. 289 

and relations of these parts are gradually developed. In case tlie 
prolapsus proceeds to the third degree, the pelvic floor gives way 
under the influence of the continued pressure. The perineal mus- 
cles become overdistended and the vulva enlarged, until the uterus 
is permitted to protrude without resistance. 

In the second order of the development of prolapsus — that is, 
where the loss of the pelvic floor is the starting-point of the mal- 
position, the first lesions appear in the vagina. The walls of the 
vagina at the introitus begin to protrude and their descent is gener- 
ally attended with increase of tissue. Usually both walls prolapse 
together, but in many cases one or the other takes precedence. As 
the prolapsus progresses the bladder and anterior wall of the rectum 
descend, producing rectocele and cystocele. In due time the uterus 
follows with all the changes in its supports already described above. 
There are cases in which the prolapsus begins at the lower part of 
the vagina, while there is no apparent injury of the pelvic floor. 
This has been accounted for by imperfect involution of the vagina 
after child-bearing. The large, heavy, and lax walls of the vagina 
make undue pressure upon the pelvic floor and it gives way before 
them. A similar state of things occurs, so far as appearances are 
concerned, where there has been subcutaneous laceration of the mus- 
cles of the pelvic floor which impairs its function. 

Prolapsus of long standing changes the structure of all the 
tissues. Atrophy of the muscular tissue of the vagina and pelvic 
floor occurs, and the ligaments of the uterus lose their character- 
istics so that they can not be restored to their original state by any 
means. 

There is a prolapsus which occurs as the result of degeneration 
of the supports of the uterus. It occurs in feeble old women in 
whom general nutrition is greatly impaired. The perinseum and 
vagina lose their elasticity, the adipose and areolar tissue disappear, 
and the vaginal walls, bladder, and atrophied uterus descend. Such 
patients are also subject to prolapsus of the rectum and sometimes 
prolapsus of the mucous membrane of the urethra. I have called 
this senile prolapsus to distinguish it from the ordinary descent of 
the uterus which usually occurs in middle life. I believe it to be 
due to the general atrophy of the pelvic viscera because of the time 
of life when it occurs, and the fact that I have seen it in those who 
have not borne children. The first case that I carefully studied was 
in an old maiden of seventy years of age. 

Symptomatology. — The natural history of prolapsus uteri as 
manifested by symptoms and physical signs, diflers to some extent 
20 



290 DISEASES OF WOMEN. 

in different cases, though the pathological conditions appear to be 
the same in all. The suffering caused varies according to the general 
health and nervous sensitiveness of the subjects affected. What is 
more strange still, is the fact that incomplete prolapsus often causes 
more suffering than the more advanced stages. It is not an uncom- 
mon thing to see a patient with complete prolapsus of the uterus 
who complains less than another in whom the uterus is still within 
the pelvis. 

The sj'naptoms indicative of prolapsus uteri maybe classed under 
two heads : First, the derangement of the functions of the other 
pelvic organs, and, second, the disordered nutrition of the tissues of 
the pelvic viscera generally. The dragging of the uterus upon the 
bladder and rectum, and the abnormal pressure cause irritation, 
which gives rise to rectal and vesical tenesmus. The constant desire 
to evacuate the rectum and bladder, is often very distressing. These 
symptoms are greatly aggravated by walking, lifting, coughing, and 
especially by standing, and they are all relieved in a very marked 
degree, often completely so, by lying down. This difference in 
the feelings of the patient, when in the erect or recumbent posi- 
tion, is a diagnostic point of very great value. The recumbent po- 
sition generally gives relief in the majority of the diseases of the 
pelvic organs, but not so markedly as in displacements of the uterus. 

The malnutrition produced by irritation and deranged circula- 
tion leads in time to inflammatory affections of the uterus and other 
pelvic organs. This is not an acute inflammation which can be seen, 
but a hypersemia accompanied by tissue changes such as areolar hy- 
perplasia and catarrhal states of the mucous membrane. It is prob- 
able that the endometritis so common in prolapsus uteri may, in 
many cases, precede the displacement, but the displacement certainly 
tends to keep it up. The symptoms of these affections need not be 
given here. 

The symptoms manifested by the general system in this affec- 
tion are not marked nor special. Beyond the backache and deranged 
digestion which often accompany prolapsus, and the depression which 
comes from a consciousness of having some chronic ailment which 
impairs locomotion and general usefulness, there is not much that 
need be mentioned. 

Physical Signs. — In prolapsus in the first degree, the utenis 
presses the posterior vaginal wall downward, and encroaches upon 
the rectum to some extent, at the same time it inclines backward. 
In some cases the cervix rests so heavily upon the floor of the pelvis 
that it becomes flattened. This is easily detected by digital exam- 



DISLOCATIONS OF THE UTERUS. 



291 



ination, which reveals the descent of the uterus. The space from 
the pubes to the anterior wall of the body and fundus uteri is en- 
larged and remains so when the bladder is empty. The upper per* 
tion of the vagina is often relaxed and wider than normal. 




urethra 



posterior 



anterior 
all 



Vaginal 



cervix 
Fig. 137.— Prolapsus uteri with cystocele. 

In the second degree of prolapsus, the os points toward the os- 
tium vaginae, and is at or near the vaginal outlet. The fundus uteri 
lies back toward the sacrum but not usually so far as in marked re- 
troversion. In complete prolapsus the uterus protrudes from the 
vagina, and can be easily recognized by inspection. In this third 
degree of prolapsus, the bladder and anterior wall of the rectum 
are usually drawn wdth the uterus, and in extreme cases, the urethra 
also. The extent to which these organs accompany the uterus in its 
descent varies considerably. This may be determined by passing a 
sound into the bladder and ascertaining its direction, and the same 
means will show the extent of the prolapsus of the rectal walls. 



292 



DISEASES OF WOMEN. 



Diagnosis. — Tlie afiections which simulate prolapsus uteri are 
hypertrophic elongation of the cervix, fibrous polypus, and inver- 
sion. A polypus and an inverted uterus may be excluded by the 
absence of the os and cervical canal, and by the fact that they are 
covered with the mucous membrane of the uterus, while the pro- 
lapsed uterus is covered with the mucous membrane of the vagina. 

The elongation of the neck of the uterus can be detected by 
passing the sound, and at the same time pushing the uterus up into 
the pelvis, until the fundus can be detected by palpation of the ab- 
domen ; that is, by making the bimanual examination. The fact 
that this hypertrophy of the cervix occurs, as a rule, in those who 
have not borne children, will also aid in the diagnosis. There are 
cases of prolapsus in which the uterus is greatly relaxed, and be- 
comes elongated, so that the sound, when passed to the fundus, 
shows a great increase in its long diameter. By replacing the uterus 
it becomes shortened very considerably ; the shortening, I presume, 
is due to contraction or condensation of the tissues. This has been 
described by Emmet as a process of telescoping, but I think the 

term is ill chosen. One can not 
conceive of portions of the 
uterus being pushed into each 
! other like sections of a tele- 

scope. 

In the physical examination 
of prolapsus, care should be 
taken to discover any compli- 
cations which may exist, such 
as neoplasms of the uterus, 
which greatly increase its size, 
abdominal tumors which crowd 
the uterus downward, and atro- 
phy of the muscles of the pel- 
vic floor and vagina. 

Causation. — The fine ad- 
justment of the uterus and the 
means which keep that organ in 
its place, and yet permit con- 
siderable motion, are such that 
any increase of weight of the 
one, or loss of strength of the 
other will cause displacement. The formation of the pelvis, and its 
position in relation to the vertebral column : the character of the 





"^j 



Fig. 138. — The shallow pelvis with lessened 
inclination of brim. The direct action of 
the pressure from above is shown by the 
arrows. 



DISLOCATIONS OF THE UTERUS. 



293 




Fig. 139. — Increased inclination of in- 
let. Pelvic organs escape pressure. 



fiber of the uterine supports, the quantity and consistence of the 
areolar and adipose tissue ; one's habits in regard to clothing, posi- 
tion in standing and sitting, if main- 
tained unduly long, character of oc- 
cupation, strength or weakness of 
general organization ; and the acci- 
dents and injuries incident to child- 
bearing, all have certain influences in 
causing dislocations of the uterus. 

A shallow and wide pelvis (Fig. 
138) which is more than sufiicient 
for the accommodation of its con- 
tents, while it is favorable to easy 
parturitions, predisposes to descent 
of the uterus. Again, if the pelvis 
is tilted forward, so that it is brought 
more immediately under the axis of 
the abdomen (Fig. 138) the pelvic 
organs are constantly under greater 
pressure than normal, and prolapsus 
and retroversion are likely to occur. 
These facts regarding the form and 

position of the pelvis are factors of great importance in the problem 
of uterine displacement, and deserve more attention than has been 
given to them. 

The habit of walking erect has the effect of maintaining this 
favorable relation of the abdomen and pelvis, while stooping disturbs 
this harmony of relative positions. In this, both in regard to forma- 
tion and habit of standing and walking, there is the greatest diversity 
among women. The tissues of the uterine supports, when defective 
in quantity or quality, are incapable of performing their functions. 
These efliects may be the result of imperfect development sach as 
occurs in those of sedentary habits in youth, or they may come from 
debilitating diseases. In the one case they have never been well de- 
veloped, and in the ofcher they have become atrophied. Standing 
and walking to an extent that is fatiguing, bring undue strain upon 
the pelvic organs, and if persisted in, will in time produce prolapsus. 
Active exercise, with liberal periods of rest, will tend to strengthen 
the uterine supports, but fatigue will overcome their power of re- 
sistance. Stooping forward while in the sitting position has a two- 
fold injurious influence — it interrupts the return-circulation in the 
pelvis and impairs the nutrition of the organs and brings increased 



294 DISEASES OF WOMEN. 

downward pressure to bear on them. The position of the girl at 
the sewing-machine and that of the lady of leisure, bent over in her 
easy-cliair while reading a novel, are alike hnrtful, but worst of all, 
the school-girl, bending over her desk all day, while her body is, or 
should be developing, suffers the most injury. Among the errors 
in the use of clothing, the abuse of corsets does the most harm. I 
would not be understood as condemning corsets. Long use has ren- 
dered that kind of support necessary to highly civilized women, but 
tight-lacing forces the abdominal viscera out of place and in time 
displaces the pelvic organs. 

Heavy lifting, if persisted in, is a cause of displacement. This 
is noticed among the poor who do heavy work. The women of In- 
dia, who were at one time supposed to bear children with ease and 
impunity, and to suffer less from uterine affections than our Ameri- 
can women, are very subject to complete prolapsus uteri, caused no 
doubt from their want of care after confinement and. in carrying 
heavy burdens. General weakness, induced by exhausting diseases 
and extreme old age, affects the pelvic organs very decidedly. This, 
no doubt, is the cause of prolapsus uteri in women with consump- 
tion and in the very aged. 

The most important, certainly the most frequent, causes of uter- 
ine displacement are the injuries and improper management incident 
to child-bearing. The condition of the uterine supports after partu- 
rition is that they are all greatly enlarged through the growth of 
gestation, and, while they are competent to maintain the large uterus 
which rests in the abdominal cavity, they must undergo involution 
in conjunction with the diminution of the uterus. If this involu- 
tion fails in the uterine ligaments and vagina while it goes on in the 
uterus the supports fail, because they are too long and relaxed. Im- 
perfect involution, not only of the uterus but of all the other tissues 
and organs of the pelvis, is seen to give rise to displacement. This 
imperfect involution may be due to post-partum inflammation or to 
the patient resuming the active duties of hfe before involution is 
completed. In regard to the injuries of the pelvic floor and their 
effect on the position of the uterus the reader is referred to the 
chapter on that subject. 

Finally, enlargement of the uterus, whether from imperfect in- 
volution, inflammation, or the presence of neoplasms, will cause 
prolapsus. This will occur although all the supports may be nor- 
mal ; the balance between the supports and the organs to be sup- 
ported being disturbed by the increased weight of the uterus, de- 
scent will occur. 



DISLOCATIONS OF THE UTERUS. 295 

It should also be borne in mind that the abnormally large uterus 
will prolapse in spite of the normal supports, while, on the other 
hand, defective supports which permit a normal uterus to descend 
will give rise to enlargement of the uterus by congestion, swelling, 
and, linally, hyperplasia, and by this increase of weight will incline 
it to remain ^displaced. 



TREATMENT OF PROLAPSUS UTERI. 

There are four important objects to be attained in the treatment 
of prolapsus uteri : to restore the displaced organ, to keep it in place, 
to restore the supports of the uterus, and to remove complications 
and accompanying affections if any such exist. 

The restoration of the uterus to its proper place is performed as 
follows : The patient is placed in Sims's position, and, if the pro- 
lapsus is complete, the uterus is grasped in the hngers, and, while 
compression is made, it is pushed upward in the axis of the pelvic 
cavity. By these means the displacement is reduced from the third 
degree to the second ; then the perinseum should be retracted with 
Sims's speculum, and with two sponges in holders the uterus should 
be raised to its normal elevation. Difficulty in accomplishing this is 
sometimes caused by the fundus uteri turning backward while the 
upward pressure is being made, so that, in place of overcoming the 
displacement, the prolapsus is changed to a retroversion. This can 
be guarded against by making the pressure mostly on the posterior 
side of the cervix. Passing the sound and making it guide the 
uterus in the right direction while upward pressure is being made is 
another way of managing difficult cases. While these manipulations 
are being made the patient should relax the abdominal muscles by 
avoiding all straining. Many patients fail to obey orders in this 
respect ; they continue to hold the breath, and strain as if preparing 
to resist the pain of some injury about to be inflicted upon them. I 
have overcome this annoyance by causing the patient to take long 
regular respirations while being treated. In rare cases, in which 
much difficulty is met in replacing the fallen uterus, the patient 
should be placed in the knee-chest position, and then the chances are 
that the uterus will slip back to its position Mdthout much help. If 
any aid is needed it can be given by the sponges in holders, or what 
is quite as good, if not better, in manipulating with the patient in 
this position, is to use one or two fingers in place of the sponges. 
With a very limited experience and a knowledge of the methods 
described any one can manage this portion of the treatment. To 



DISEASES OF WOMEN. 

keep the uterus in place is the question wliich is not easily settled. 
The object of all the mechanical means which may be employed is. 
Urst, to keep the organ in position and thereby give rehef. At the 
same time through the agency of the artificial support, and other 
means, to restore the natural supports. 

If the prolapse is not beyond the second degree, and is due to 
relaxation only of the uterine supports, and not associated with any 
injury that destroys the integrity of the pelvic floor, the uterus may 
be retained by means of a pessary or tampon until the supports 
recover their original strength. In connection with these mechani- 
cal means, rest in the recumbent position is one of the most im- 
portant factors in bringing about the desired result. 

The material used for the tampon should be absorbent cotton, 
wool, or lint. To simply keep the uterus in place the cotton is no 
doubt the best. It is soft and most agreeable to the tissues. When 
there is any vaginitis or endometritis causing a free discharge, ma- 
rine lint does better. It takes up the discharge, disinfects it, and 
prevents decomposition. This it does better than the cotton. In 
some cases the hnt is irritating to the tissues and can not be long 
continued. Sometimes I have alternated the use of the cotton and 
lint with much satisfaction. 

Since the introduction of antiseptic material for dressings, the 
tampon has been far more useful in surgery. In the past when 
sponges, not well prepared, were used, they could be retained in 
place but a few hours without causing decomposition. 'Now the 
marine lint or borated cotton can be worn twenty-four or forty-eight 
hours without being offensive. 

For those who have vaginitis or any inflammation of the utems I 
direct that the tampon be applied in the morning after having used 
the douche of hot water, plain or medicated. At night the tampon 
is removed and the douche again used and afterward the tampon re- 
placed, if the uterus will not stay in place without it, but omitting 
it for the night if the recumbent position will overcome the tend- 
ency to displacement. When there is no inflammatory complication 
the tampon may be left in place two days and a night. At the end 
of the second day it should be removed at bed- time and replaced 
next morning, the douche being used after removal and before intro- 
ducing it again. 

Astringents of various kinds have been employed with the tam- 
pon, the cotton being saturated with the solution to be used, or the 
agent may be employed in powder. The latter is much the prefer- 
able way when the milder astringents are selected. As a rule I pre- 



DISLOCATIONS OF THE UTERUS. 297 

fer the borated cotton or marine lint alone, using such astringents as 
may bo required in the douche. 

In many cases there is some loss of the pelvic floor from pre- 
vious injurv. This structure should be restored as soon as the tis- 
sues are in a condition to warrant surgical treatment. As a rale, in 
those cases (jf prolapsus which have existed for some time, the nu- 
trition of the tissues is impaired and needs treatment preparatory to 
operating. For a more complete discussion of this subject the 
reader is referred to the chapter on injuries of the pelvic floor. 

Keeping the uterus in its position by the tampon and other 
means of support has the effect of not merely relieving the prolapsus, 
but also of giving the uterine ligaments every chance to regain their 
normal condition. Artificial support is palliative and curative as 
well. The mechanical supports used in the treatment of prolapsus 
include a variety of devices. The pessaries used are of two kinds — 
those that are placed in the vagina and are held in position by the 
pelvic floor, and those that are held in place by being attached to a 
strap round the waist. The former are applicable in the first and 
second degrees of prolapsus while the pelvic floor remains normal or 
nearly so. The latter are used in complete prolapsus, and in those 
cases where there is so much loss of the pelvic floor that it will not 
keep the pessary in position. When the perinseum is sufl&cient to 
support the vagina and the prolapsus is limited to the flrst or second 
degree, the instrument known as Peaslee's pessary answers very well. 
It is a simple ring made of whalebone and covered with soft rubber 
(see figure). When in position it rests upon the pelvic floor. It 
should admit the cervix without making pressure upon it, and should 
fit the upper portion of the vagina without distending it to any ap- 
preciable extent. It acts by carrying the upper portion of the vagina 
and the cervix backward into the normal position, and at the same 
time raises the uterus to a very slight, but sufticient extent. If 
well adapted it takes off the pressure from the lower part of the 
vagina and permits it to contract and regain its tonicity. Fig. 137 
represents prolapsus in the second degree. Fig. 140 shows the pes- 
sary in position after the uterus has been replaced. 

When there is relaxation of the pelvic floor due to the prolapsus 
it is necessary to keep the patient at rest much of the time during 
the first week or two that the pessary is worn. If this is not prac- 
ticable a perineal band should be worn to support the pelvic floor 
while the patient is exercising. In the progress of the treatment 
the vagina should contract when the uterus is supported by the 
pessary. This, in time, requires that a smaller instrument should be 



298 DISEASES OF WOMEN. 

used. The rule is that the smallest instrument should be employed 
that will keep the uterus in place. If too large a pessary is used it 




Fig. 140. — Uterus replaced, with pessary in position. 

will keep the uterus in place, but will overdistend the vagina and 
weaken the supports of the uterus in place of restoring them. 

One great advantage which the ring pessary has is in being 
easily introduced or withdrawn, and that it does not become displaced 
except to settle downward, and this can be easily corrected by the 
patient assuming the knee-chest position from time to time. 

When the uterus inchnes to retrovert after having been elevated, 
a common occurrence, a retroversion pessary will act better than the 
ring, but the use of that instrument will be more fully discussed 
under the head of retroversion. 

Prolapsus occurring after the menopause when the uterus has 
undergone final involution, may be relieved in some cases by the old 
glass-globe pessary. It certainly is the best instrument that I have 



DISLOCATIONS OF THE UTERUS. 299 

found for old patients having prolapsus of the vaginal walls, bladder, 
and the remains of the atrophied uterus, if the pelvic floor remains 
sufficient to support the pessary. It simply keeps the uterus and 
bladder up in the pelvis by distending the vaginal walls. The ute- 
rus may be anteverted or retroverted, but is so small that it makes 
no difference what position it occupies so long as it is kept high 
enough up. 

The globe is easily used. In fact no mistake can be made with 
it except to use one that is too large. This must be avoided, be- 
cause one that is too large will cause vaginitis and ulceration. It 
is a fact also that the pessary which answers when first used will be 
too large when the parts regain some of their original tonicity. 
For a time the patient should be kept under observation and the in- 
strument changed to suit. This globe pessary is the most trouble- 
some instrument to remove. I have usually succeeded by using a 
small Sims's speculum and a Sims's vaginal depressor, and seizing 
the instrument between the two and making traction. When this 
fails, a pair of miniature obstetric forceps should be made out of 
strong copper-wire, by doubling it to form loops and twisting the 
ends to make the handles. "With this the globe is very easily 
grasped and removed. The intra- vaginal pessaries, such as the ring 
and globe already mentionedj and all others that rest wholly within 
the vagina are liable to slip down and give the patient great dis- 
comfort, and sometimes they come away entirely. This is especially 
the case when flrst introduced. To obviate this, a perineal band 
should be worn until the peringeum, upon which the pessary de- 
pends for support, regains its tonicity. By this arrangement the 
same results are obtained as by the use of the cup and stem pessary, 
to be noticed hereafter — in fact, better results so far as the comfort 
of the patient and the final effects are concerned ; therefore, I have 
always endeavored to relieve prolapsus when possible by the intra- 
vaginal pessary. 

Several uterine supporters have been devised to meet the require- 
ments of cases in which the pelvic floor is relaxed from long disten- 
tion, so that it has not power to sustain a pessary in position, and 
the patient's circumstances will not permit long rest in the recum- 
bent position and the use of the tampon. 

They are all constructed on similar principles of mechanism and 
action — namely, cup and ring to receive the cervix uteri, and a stem 
attached which projects from the vagina and is fastened to a perineal 
band, which in turn is attached to a waistband. The advantages 
claimed for this kind of uterine supporter are that if properly ad- 



300 - DISEASES OF WOMEK 

justed it will certainly keep the uterus in place, and the patient can 
remove and readjust it when desirable. These are valuable features 
no doubt, and may be fairly claimed for the instrument as a rule, 
but not without many exceptions. There are cases where this form 
of instrument, while it will keep the uterus at its proper elevation, 
will not keep it in its proper axis without very great care in its ad- 
justment. Under such circumstances the patient can not remove and 
replace the pessary with any satisfactory results. While pushing up 
the uterus, during the introduction of the pessary, a retroversion 
takes place, and wearing the instrument only aggravates that form of 
displacement. The further objections which may be placed over 
against the advantages of this kind of pessary are that it can not 
be worn for any great length of time without doing harm and caus- 
ing great discomfort, and where in a given case the patient can not 
adjust it properly herseK it will do more harm than good, and should 
not be employed on any account under these conditions. Again, in 
the most favorable cases, it is a constant source of irritation, less or 
more. The vulva is irritated by its presence and usually becomes 
inflamed in time ; the pressure of the cup against the cervix and 
upper end of the vagina causes inflammation and ulceration, if the 
patient takes much active exercise. The reason for this is that the 
pessary is firmly fixed by its support outside of the body and the 
movements of the pelvic organs against this fixed instrument cause 
great friction. The intra- vaginal pessary moves with the pelvic 
organs, but the stem pessary does not accom- 
modate itself to the requirements, and hence 
its power to do harm. 

From the little that has been said, it will 
appear that the use of the vaginal stem pes- 
sary for the relief of prolapsus is most unsat- 
isfactory. All that can be said of such means 
of support is, that in some cases they may be 
used for a time in the hope of helping to 
restore the natural uterine supports. Dr. 
Paul F. Munde has truly said, " The ideal 
pessary for complete prolapsus uteri is yet 
undiscovered." The instrument which I have 
^Modifitatbf o?CuS?' foi'"i"d t<> answer best of the stem pessaries is 
a modification of Cutter's (Fig. 14-1). 
These pessaries should be fitted with care, and just here another 
difficulty is encountered in the fact that they are all made of one 
size and shape, so that it is difficult to change them to suit special 




DISLOCATIONS OF THE UTERUS. 301 

cases. This I have tried to overcome by making the stem flexible, 
or rather so that it can be molded, and capable of being shortened, 
so that it can be made to suit each case. 

Fortunately, stem pessaries are rarely needed, and, I may say, 
that every year I find less need for them. 

By a careful and judicious use of the ring and the tampon, aided 
by the T-bandage to support the pelvic floor, one can accomplish 
nearly all that can be done by these artificial supports. 

The important facts in connection with pessaries already men- 
tioned, may be recapitulated here, and they should be borne in mind. 
They are as follows : First, these means of relief for prolapsus most- 
ly are temporary and palliative, and can only keep the uterus in 
place until the tissues are prepared for the operation of perineor- 
raphy when the pelvic floor has been injured ; second, they keep 
the uterus in place till the normal supports are restored ; and, third, 
they reduce a complete prolapsus to an incomplete, when an intra- 
vaginal pessary will answer the purpose. 

While these artificial means of support are being employed, ef- 
forts should be made to strengthen the parts and to remove all com- 
plications which tend to keep up the prolapsus, astringent injections 
should be continued, standing and walking should be limited to an 
amount which is sufiicient for exercise, and lifting heavy weights 
and wearing tight and heavy clothing should be avoided. The bow- 
els should be kept free, so that straining at stool may be unneces- 
sary. This last point should be carefully attended to. Constipation 
is a potent cause in producing and keeping up prolapsus. The gen- 
eral health should be cared for, and if there is any debility it should 
be met by the proper tonic treatment. 

In some of the most favorable cases complete relief will be ob- 
tained by the means described, so that all mechanical supports can 
be given up. Care should be taken not to remove the pessary too 
soon. I have found in cases of prolapsus that it is best to reduce 
the size of the pessary by changing from time to time to a smaller 
one. 

Martin, of Berlin, has reported one hundred and ninety-two cases 
in which he has operated for the cure of prolapsus. In all but six 
he was obliged to perform an operation upon the cervix ; in three 
instances it was necessary to extirpate the entire uterus. In one 
hundred and seventy-one cases silk sutures were used, in seventeen 
the continuous catgut, the latter being highly commended, al- 
though it is noted that it is not safe to depend entirely upon these, 
as secondary haemorrhage may occur if they are not re-enforced with 



302 DISEASES OF WOMEN. 

silk. Relapses occurred only eleven times, and those, too, in old 
subjects. The operations performed were anterior and posterior 
kolporrhaphy, with perineorrhaphy. 

In comparing mj own results with the above, I hnd that I have 
succeeded as well by the combined use of mechanical supports and 
surgical operations. That in the treatment of prolapsus, where op- 
erating upon the cervix uteri and pelvic floor has failed, kolpor- 
rhaphy has also been useless. I have, therefore, abandoned that op- 
eration. 



TREATMENT OF PROLAPSUS BY GALVANO-CAUTERY. 

Dr. John Byrne, of Brooklyn, has treated successfully nine cases 
of prolapsus of the uterus by galvano-cautery. In three, the cervix 
uteri was completely amputated with the galvano-cautery. The 
other six were treated by partial amputation of the cervix. The de- 
scription of the operation is given by Dr. Byrne as follows : 

" A diverging double tenaculum was passed into the cervical 
canal and flxed in the tissues so as to secure complete control of this 
part. The entire mass was next returned within the pelvic cavity, 
and the uterus elevated sufficiently to show the line of vaginal in- 
sertion in its entire circumference. "While in this position, a small 
platinum knife, brought to a red heat, was slowly carried around the 
base of the cervix, close up to the vaginal fold, and to a depth suffi- 
cient to accommodate a platinum loop, and to insure it against slip- 
ping. The latter was next adjusted, and the amount of battery im- 
mersion being duly estimated to guard against overheating of the 
wire, the loop was slowly and with intermissions contracted, until 
about one quarter of an inch in depth had been reached. The ^dre 
was now removed, and a firmly-rolled tampon, one and a half inch 
in diameter and four inches long, smeared with glycero-tannin, 
having four per cent of carbolic acid, was passed into the vagina, 
and a T-bandage applied." 

Two of the six cases required linear cauterization of the vagi- 
nal walls as well as partial amputation. The following is Dr. 
Byrne's description of the operation : 

" The parts having been returned as in the former case, the line 
of vaginal insertion was noted, and merely marked in spots by the 
cautery knife. The entire mass was then brought down and out, 
and with the same instrument a deep, circular fissure about three 
eighths of an inch in depth was made around the entire circumfer- 
ence of the cervix3 the knife being carried upward and inward in 



^ 



DISLOCATIONS OF THE UTERUS. 303 

the direction of the os internum, and precisely as I am accustomed 
to do in suitable cases of carcinoma. This being done, three diverg- 
ing fissures were made, one central, one toward either side on the 
anterior, and one only on the rectal surface, starting from and con- 
necting with the circular incision for a distance of about three 
inches ; care being taken that the entire depth of the hypertrophied 
vaginal membrane should be incised." 

I am unable to speak from experience regarding this method of 
treating prolapsus of the uterus. The histories of the cases given 
by Dr. Byrne in the " Transactions of the American Gynecological 
Society " for 1886, are very satisfactory. 



CHAPTER XVIII. 



EETEOVEESIOX OF THE UTEErS. 



Heteoyeesiox of the uterus is a chanD;e in the axis of that oro^an 
in which the fimdiis points toward the sacrum and the cervix tm-ns 
toward the symphysis pubis or vaginal outlet. This displacement 
varies in extent in different cases ; three degrees are usually de- 
scribed. In the first degree the fundus points toward the promon- 
tory of the sacrum ; in the second the uterus lies almost transversely 
in the pelvis ; and in the third the fimdus is low down in the pel- 
vis, while the cervix is thi'own upward at a higher elevation than 
the fundus. 

Eeti'oversion is ustially progressive, except in the first months of 
pregnancy and in the puerperal state. In these conditions retrover- 
sion may occur abruptly, and so it may under other circiunstances, 
but usually it comes on gradually, passing from the first degree to 
the second, and on to the third. 

It is exceedingly rare to find retroversion in the first degree ex- 
isting for any length of time, the displacement usually passing on to 
the second and third degrees. 

The anatomical changes which take place in backward displace- 
ments are to some extent the same as those found in prolapsus. 
The same changes in the supports of the uterus are found, and 
though differing in detail are the same in kind. This arises from 
the fact that nearly every case of prolapsus is associated with more 
or less retroversion, and in nearly all cases of retroversion there is 
also a slight prolapsus. These changes have been discussed under 
the head of prolapsus, hence it is only necessary for me to point 
out here the anatomical features which are j)articularly concerned 
in retroversion. 

In retroversion there is shortening of the posterior vaginal wall 
by contraction. The exceptions to this are when there is rectocele, 
and in recent cases in which the vaginal wall is apparently short- 



KETROVERSION OF THE UTERUS. 



305 



ened, but in reality is thrown into folds. The anterior vaginal 
wall is generally distorted rather than displaced. Its upper end is 




Fig. 142. — The three degrees of retroversion. 

crowded upward and sometimes forward by the cervix uteri, and its 
lower part is sometimes pressed downward and forward, giving it 
the appearance of a urethrocele. 

The relations of the cervix and vagina are changed more or less 
in the majority of cases. In some the projection of the cervix into 
the vagina is apparently very much increased posteriorly. To the 
touch the vagina appears to be attached to the whole length of the 
cervix. This is apparent, not real, and is usually found so Avhen 
the vagina has still maintained its tonicity. In other cases, with 
marked shortening of the vaginal wall, the invagination of the cer- 
vix is lessened. Nearly always the invagination of the cervix ante- 
riorly is less than normal. The position of the uterus as regards 
elevation varies greatly in different cases. This may be normal in 
the pelvis, simply changed in its axis, or it may be prolapsed so that 
the cervix is close to the vulva, the anterior vaginal wall being much 
shortened. Again, the posterior wall of the nterus may rest upon 
21 



306 



DISEASES OF WOMEN. 



the pelvic floor and altogether be placed far back in the pelvis, so 
that the fundus presses upon the rectum, wliile the bladder maj not, 




FtG 143. — Retroversion of the second degree. 

as a rule, be much affected, either in its position or function, vet it 
frequently is. The weight of the nterus being removed from be- 
hind there is nothing except the vesical ligaments to prevent the 
bladder from extending backward when distended. It then rests 
upon the retroverted nterus instead of rising np toward the abdomi- 
nal cavitv, and the ovaries and Fallopian tubes are to some extent car- 
ried backward and downward with the nterus. The extent of this 
displacement varies greatly. In some cases there is complete pro- 
lapsus of one ovary, or of both of these organs, so that they he in 
the sac of Douglas and the uterus rests npon them. In other cases 
the ovaries rest npon the retroverted uterus. One case of this kind 



KETROVERSION OF THE UTERUS. 307 

I well remember to have operated upon. Tlie ovaries were diseased 
and gave so nnicli trouble that I decided to remove them. One was 
in its normal position, the other, the right one, was adherent to the 
side of the uterus. This prolapsus of the ovaries is one of the 
worst complications of retroversion. 

There is a stronglj-pre vailing opinion that the circulation in the 
pelvic organs is much deranged by retroversion, and that changes of 
structure of these organs follow in consequence. How far this is a 
fact it is difficult to determine. It is true that in nearly all cases of 
retroversion are found some congestive inflammatory trouble and 
structural changes, either from degeneration or hyperplasia, but 
whether these changes preceded the version and perhaps aided in 
producing it, or whether they resulted from the change of position, 
can not at all times be ascertained. There is good reason for be- 
lieving that all malpositions cause deranged nutrition which in time 
lead to organic changes, and still such pathological conditions are 
found when there is no displacement, showing that these relations of 
cause and effect are interchangeable in displacements and some other 
diseases of the uterus. 

COMPLICATIONS. 

There are cases of retroversion so complicated that they are per- 
manent and incurable. These should be clearly understood ; hence 
I refer to them briefly in this connection. 

There are two classes of such cases : Those which have had pel- 
vic peritonitis while the uterus was retroverted, the adhesions made 
by the products of the inflammation permanently fixing the uterus 
in its malposition. I presume that a similar result is sometimes 
produced by pelvic peritonitis, the products of which (behind the 
uterus) will by contracting drag the uterus into the position of re- 
troversion. This complicated form of retroversion has been con- 
sidered incurable, but recently encouraging eftorts have been made 
to relieve it by surgical treatment. This subject will be referred 
to and discussed at the end of this chapter. The other class is 
one in which a similar condition occurs as the result of malfor- 
mation or congenital malposition. In cases of this kind the uterus 
is retroverted, the posterior vaginal wall short and rigid, the utero- 
sacral ligaments are short and rather unyielding, and although the 
uterus is slightly movable it can not be restored to its proper place. 
In such case the pelvis is wide and shallow, and there is often a 
lack of cellular tissue around the pelvic organs. When I first had 
my attention directed to this class of cases I presumed that they 



308 DISEASES OF WOMEN. 

must have had pelvic peritonitis, but in many of tliem there was 
no evidence obtained from the past history to warrant any such 
conclusion. Further investigation satisfied me that the lesions 
were the result of perverted development and growth. Some of 
these cases do not suffer much, but they are sterile as a rule. 

Symptomatology. — The clinical history of retroversion, so far as 
the symptoms are concerned, is not sufficiently definite to be diag- 
nostic. Many of the symptoms are common to prolapsus and cer- 
tain other affections of the uterus. Another curious fact is that 
the suffering caused by retroversion varies greatly in different pa- 
tients. The rule is that retroversion causes much discomfort, but I 
have seen one patient who had retroversion for many years and yet 
was one of the most active women I have ever known, and was per- 
fectly free from all evidence of any affection of the pelvic organs. 

The symptoms which belong more especially to retroversion are 
rectal tenesmus and the feeling of obstruction to a free action of the 
bowels. 

Backache, general pelvic tenesmus, aching of the limbs, irritation 
of the bladder and rectum, neuralgic pains in the pelvis, and the 
fact that these symptoms are aggravated by walking and standing 
and are relieved in the recumbent position, are all evidences of re- 
troversion, but also occur in prolaj)Sus. 

Menstruation is frequently deranged and menorrhagia, dysmen- 
orrhoea of a mild form, and irregular recurrence of the menses, have 
all been traced to this form of displacement ; but all these are more 
frequently caused by other affections. In several cases that I have 
seen, the menstrual discharge was offensive and very distressing to 
the patient. This symptom I have noticed more frequently in retro- 
version and retroflexion than in any other affection of the uterus. 

Physical Signs. — The physical signs are obtained by the touch 
and uterine sound. The vaginal touch reveals the os uteri pointing 
toward the introitus vulvae, or in extreme cases, toward the sym- 
physis pubis. The anterior vaginal wall is often found projecting 
downward in front of the cervix. The upper portion of the pos- 
terior vaginal wall is found to be pressed downward and forward, so 
that the junction of the posterior cervical wall of the uterus and the 
vagina are much nearer to the vulva and more easily touched with 
the finger. In some cases this prolapsus of the posterior vaginal 
wall is very marked, and appears to aggravate the version by push- 
ing the cervix against the bladder. 

If the bladder is empty and the muscles of the abdomen are re- 
laxed, the bimanual examination will show that the uterus is not in 



KETROYERSION OF THE UTERUS. 309 

its normal position, but must be retroverted, as indicated by the signs 
obtained bv the vaginal touch. These signs of retroversion, while 
quite reliable, might, in rare or complicated cases, be misleading, so 
that it is well to confirm or correct by the use of the sound the evi- 
dence obtained by the touch. Placing the patient on the left side 
and using Sims's speculum, the sound can be passed with ease, and 
its direction will show the dislocation of the uterus. 

In doubtful or complicated cases, when all the evidence is needed 
that can be obtained, the rectal touch may be employed. The finger 
in the rectum can be swept all around the fundus and body of the 
uterus while it lies low down in the sac of Douglas in the retro- 
verted state. The rectal touch can be made more effective still by 
making the abdominal or vaginal touch at the same time. By these 
means of examination a diagnosis can be made with the greatest cer- 
tainty, and proof of the accuracy of the diagnosis may be obtained 
by replacing the uterus. Regarding the conditions which may be 
mistaken for retroversion and the differentiation little need be said. 
The question which most frequently arises is whether there is retro- 
version or retroflexion. This can always be settled by the evidence 
obtained from the physical signs already obtained, and the fact that 
in flexion the uterus is bent upon itself, a fact that is noticed by the 
touch and confirmed by the use of the sound. 

Causation. — The causes which produce prolapsus uteri are ap- 
parently the same as those which give rise to retroversion. The 
reader may refer back to the causation of prolapsus for the facts re- 
garding this matter. This will save repetition. It is clearly evident, 
however, that while there may be much in common in the causation 
of the two forms of uterine displacement, prolapsus and retrover- 
sion, there must be some difference in the causes which produce such 
different effects. This appears to have been quite an obscure sub- 
ject, for I find that the text-books are very indifferent in regard to 
it. My own observations lead me to believe that the causes of re- 
troversion are the loss of support from morbid states of the uterine 
ligaments occuring while the pelvic floor remains normal or not 
wholly useless as a means of support, and that prolapsus is due to 
defects in the uterine supports and loss of the pelvic floor also. This 
may be stated in another way, which will show what this view is 
based upon. In the great majority of cases of retroversion which I 
have seen, the pelvic floor has not been wholly wanting, in fact, in 
some of the cases it has been quite normal ; while in prolapsus it is 
usually defective. It will be easily understood that when the sup- 
ports of the uterus are defective, especially the anterior ligaments, and 



310 



DISEASES OF WOMEN. 



lessened, indeed, 



the vagina and pelvic floor are in their normal condition and keep 
the cervix uteri in place, the tendency would be for the uterus to 
fall backward into the retroverted position. 

Changes in the condition of the cervix uteri and in its relations 
to the vagina, have some influence in the causation of retroversion. 
In those who have had cellulitis, after confinement, in the tissue 
around the cervix above the vagina the invagination of the ceiwix is 
sometimes obhterated. 

The vagina to the touch is 
like a cul-de-sac^ the entire 
uterus being above the vagina. 
This condition favors retrover- 
sion. Fig. 141 shows retrover- 
sion with imperfect invagina- 
tion of the cervix uteri in a 
patient who has had cellulitis. 

Laceration of the cervix 
bilaterally j^roduces a similar 
condition of imperfect invagi- 
nation, which is often associated 
with retroversion. The ante- 
rior half of the cervix becomes lost in the anterior vaginal wall and 
the posterior part of the cervix is apparently less prominent in the 
vagina, if not really so. This is more frequently seen where the 
lateral lacerations extend above the vaginal junction, Fig. 115 shows 
this condition. 

In such cases the state of the cervix has much to do with keeping 
up the retroversion, as well as causing it. This I have demonstrated 




Fig. 144. — Retroversion with imperfect invag- 
ination of cervix due to inflammatory 
products about it. 





Fig. 145. — Apparent imperfect invagi- 
nation due to bilateral laceration of 
cervix : c, c, lips of the cervix. 



Fig. 146. — The same uterus with its 
lips drawn back into place by 
tenacula. 



KETROVERSION OF THE UTERUS. 



311 



hj trying to keep the uterus in place before restoring the cervix, and 
finding it very difficult, while it was quite easy to do so after the 
cervix was restored. The immediate effect of operating was to bring 
the cervix prominently into the vagina and sustain it there. Fig. 146 
shows the change effected in the case represented in Fig. 145, after 
the restoration of the cervix and before restoring the retroversion. 

Further evidence is also obtained to show that these mal-relations 
of the vagina and cervix, just mentioned, favor retroversion of the 
uterus in the fact that in those cases in which the cervix has been 
amputated, the uterus is generally retroverted. 

These points I consider to be of much importance and of special 
interest because they are not, so far as I know, discussed in medical 
works with reference to the causation of retroversion of the uterus. 

Treatment. — The indications are to replace the uterus and keep 
it there, and, by so doing, the supports of the uterus may regain 
their normal condition, and complete relief follow. The methods of 
replacing the retroverted uterus are to place the patient on the left 
side, and through Sims's speculum to raise the body of the uterus 
up with two sponges in holders, used as in Fig. 147. 

By upward press- 
ure the uterus can 
be raised as far as 
need be, or as far as 
possible, and then 
one of the spong- 
es should be with- 
drawn or placed in 
front of the cervix, 
and backward press- 
ure made there. 
This helps to com- 
plete the replace- 
ment, and at the 
same time holds the 
uterus in place, 
while the sponge is 
removed from its 
position behind the 
uterus. 

To succeed in this 
operation, it is ne- 
cessary to have the 





Fig. 147. — The three steps in replacing the retroverted uterus 
by means of sponge-holders. 



312 DISEASES OF WOMEN. 

bladder empty, and that the patient should not resist the efforts 
of the surgeon to replace the uterus. When there is any difficulty 
met in the practice of the method described, the patient should be 
placed in the knee-chest position (see Fig. 156), and the Sims's 
speculum used. This alone is sufficient in some cases to effect re- 
placement. When it does not do so, the upward pressure of the 
sponges behind, or drawing the cervix back with a tenaculum, will 
accomplish the object, or both sponge and tenaculum may be used. 

It is sometimes difficult to replace the uterus in cases of long 
standing, owing to the contraction of the posterior vaginal wall. 
The changes in the parts which have taken place to accommodate 
the malposition, can not always be immediately overcome. In such 
cases all that can be accomplished is to raise the uterus as far toward 
its normal place as possible, and then hold it there by means of a 
temporary support. By the use of the cotton tampon or a pessary, 
all that is gained by the first and succeeding efforts to replace the 
uterus is kept, and if the pessary is used properly it will make con- 
tinuous upward pressure upon the fundus uteri, and thereby con- 
stantly gain more and more. In cases of long standing the displace- 
ment becomes completed by slow degrees, as the tissue changes in 
the support of the uterus and vagina have taken place as the result 
of long-continued influences, and they can not be abruptly rectified. 
It takes time to undo that which it has required months and years to 
do ; hence, the process of restoration naust be accomplished by degrees 
and by repeated efforts. The details of this method of treatment 
will be given in the clinical histories of cases to be related hereafter. 

The next object to be attained is to keep the uterus in position. 
This raises the question of the mechanical supports of the uterus. I 
think that Dr. Frank P. Foster, of New York, has given the most 
rational discussion of the subject that I have seen, and I will quote 
his views later on. 



THE TREATMENT OF RETROVERSION BY THE USE OF 

PESSARIES. 

There are a great many kinds of pessaries employed in treating 
retroversion of the uterus. A few of them can be made to do much 
good when skillfully employed. The great majority of them are 
useless, and all of them are capable of doing much harm if used 
without a clear idea of how they should be used. During a discus- 
sion of displacements of the uterus at a meeting of the American 
Gynecological Society held in Boston, in 1877, Dr. E. R. Peaslee 



KETROVERSIOX OF THE UTERUS, 313 

expressed himself in favor of the use of pessaries, claiming, at the 
same time, to have obtained very gratifying results from their use 
in his own practice. In the same discussion. Dr. W. L. Atlee said : 
" I have had no experience with pessaries, at least with their intro- 
duction, but I have had a very long experience with their removal. 
I do not think that there is a day when I am at home and in my 
office, that I do not have the privilege of taking out a pessary. I 
have removed pessaries of all forms and sizes, and pessaries intro- 
duced by the most distinguished men of the profession." Peaslee 
and Atlee were certainly two members of the profession of this 
country, equally distinguished in abihty, profound judgment, and 
thorough honesty, and why they should hold such opposing views 
upon a subject so practical may not be capable of explanation by 
any one. It has appeared to me, however, that the one came to his 
conclusions from a careful investigation of the utility of pessaries 
when properly used, while the other based his opinions upon the 
fact that as generally employed, pessaries do very great harm. 
Viewing the subjects from these two stand-points, both conclusions 
are perfectly rational, and ample proof may easily be obtained of 
the good and evil which come from the use of these instruments. 

At the present day, I presume that if the harm done should be 
placed opposite the good accomplished by all the pessaries in use, 
the results would be about equally balanced. It follows, then, that 
as matters stand at this moment, it is a question whether the human 
race would be better or worse if all the pessaries were put out of ex- 
istence. 

The all-important fact remains, however, that pessaries are of 
great value, and capable of giving relief to those who suifer from 
some of the forms of uterine displacements, if properly used. The 
same may be said of nearly all valuable agents employed for the re- 
lief of suffering. That any agent, capable of giving relief when 
skillfully employed, is likely to be as potent for evil when misused, 
is a well-known fact ; hence, the object should be to attain to a more 
perfect and general knowledge of how to make and use pessaries in 
order to promote the good results, and lessen the evil. 

There are many difficulties which naturally arise in the investi- 
gation of the use of pessaries. ]^ot only do authorities differ very 
widely in their views regarding their use, but one's own experience 
is oftentimes misleading. For example, a pessary may be used to 
correct a displacement, and marked relief is obtained. The patient 
testifies to the fact that her symptoms are relieved and her useful- 
ness extended while wearing a pessary, and yet that instrument may 

21* 



314 DISEASES OF WOMEN. 

be doing harm bj still further damaging the supports of the 
uterus. 

These may appear like contradictory statements, and yet such are 
the facts observed many times in practice. The same thing is seen 
in the abuse of corsets. The lady who has contracted her waist by 
tight lacing suffers great discomfort when she goes without corsets, 
and is relieved by wearing them, and yet no one doubts the fact that 
great injury is caused by this article of wearing-apparel. 

The mechanical action of pessaries must necessarily be clearly 
understood in order that they may be employed with favorable re- 
sults ; misunderstanding on this point is no doubt the cause of much 
unsatisfactory practice. Judging from the many errors made in the 
use of pessaries, as seen in practice and from the various opinions 
expressed by writers, I am fully satisfied that this part of the subject 
is not as clearly understood as it should be by the profession gener- 
ally. My own views are so fully in accord with those of Dr. Foster, 
that I shall quote his article : 

" It can not be said that opinions are wholly agreed as to the way 
in which vaginal pessaries most commonly effect changes in the 
situation, form, and attitude of the uterus. Those who have given 
any considerable amount of thought to the matter will probably ad- 
mit (1) that a pessary may operate by virtue of mere lateral disten- 
tion of the vagina, being itself too bulky to escape readily from the 
pelvic outlet, and thus preventing the parts resting upon it from so 
escaping ; (2) that the pressure exerted by a pessary may be trans- 
mitted directly to the body of the uterus, lifting it up when ante- 
verted or retroverted, as the case may be ; and (3) that such pressure 
may operate by dragging the lower portion of the organ in a certain 
direction, thus causing its upper portion to move in the opposite 
direction. 

" While there can scarcely be a doubt that each one of these 
methods of action may explain the work done by pessaries under 
certain circumstances, it may be not only interesting as a mere 
matter of curiosity, but profitable as tending to greater precision in 
practice, to inquire into the relative frequency with which the one 
or the other actually operates, which of them is therefore of the 
greater practical importance, and which of them should be specially 
emj)hasized in teaching. The question as to whether certain pes- 
saries act as levers, or whether they are merely forced bodily in a 
certain direction, and so fulfill their purpose, is quite foreign to this 
inquiry, and, therefore, I shall not enter upon its considerations. 

" In regard to the method of action first mentioned — that of lateral 



RETKOVERSION OF THE UTERUS. 315 

or transverse distention of the vagina — it may simply be said to apply 
only to special forms of pessaries, whicli, although in common use 
before Hodge's time, have now ahnost fallen into disuse — deservedly, 
I may be allowed to add. 

" The second method, that of pressure transmitted directly to the 
body of the uterus, is undoubtedly the one that is most prominent 
in men's minds, most taken into account in practice, and most ap- 
pealed to in teaching. And yet, it seems to me, its scope is really 
quite limited, and its practical importance almost nil. If an ex- 
treme mal posture of the uterus is corrected by the act of inserting 
a pessary adapted to the case, as may often enough be done, the in- 
strument may act at lirst, I admit, by direct transmission of its press- 
ure to the body of the organ lifting the latter from a state of ex- 
treme anteversion or retroversion, as the case may be. But such 
action is only momentary ; long before it could restore the uterus to 
its normal attitude another agency is called into play, so that when 
the full action of the pessary is attained, its pressure is no longer 
transmitted to the body of the organ. In any case, then, this direct 
action on the body of the uterus is of but momentary duration, and 
accomplishes but a partial result ; and, if the malposture is not 
originally very decided, or if it is corrected before the instrument is 
inserted into the vagina, it does not come into play at all. 

" These statements embody no novelty, but they are so at variance 
with the views that seem to be held by the most influential teachers 
of gynecology, that it seems best to put forward some reasons for 
them. To illustrate, then, suppose a case of retroversion. In order 
that a pessary may fully restore the uterus to its normal attitude, 
and hold it in such attitude (acting all the time by direct pressure on 
the body of the organ), its pressure must be exerted not only upward, 
but forward, and that, too, at a point situated high in the pelvis. 
Now, from my own experience, from observation of the practice of 
others, and from the drawings employed by authors to illustrate the 
action of pessaries, I believe that pessaries long enough to fulfill 
these conditions are seldom if ever used. Granting, however, that I 
may be mistaken in this respect, it will scarcely be disputed that 
either such a pessary, besides being very long, must have a very 
pronounced curve in order to enable its middle portion to lie wholly 
below the face of the cervix while its upper end exerts the pressure 
in question (in whicli case its introduction, supposing the perinjieum 
to be intact, would be well-nigh impossible) ; or else its limbs must 
diverge to such an extent as to accommodate the cervix between 
them, making the instrument very broad, in which case it would not 



316 DISEASES OF WOMEX. 

pass between the two iitero-sacral ligaments without stretching them 
apart to such a degree as practically to shorten them, thus causing 
them to 2^1-^11 the lower poi-tion of the uterus backward, and conse- 
quently throw its upper portion forward. The result of this latter 
state of things would be that the retroversion would be corrected 
before the upper end of the instrument had been forced high enough 
to restore the body of the uterus to its normal position bj direct 
pressure upon it, or bj pressure directly transmitted to it. Further 
than this, I believe that in the great majority of instances the mere 
upward and backward pressure upon the posterior vault of the 
vagina would suffice to drag the cervix backward in the same way 
before the instrument had penetrated at all into the space included 
between the utero-sacral ligaments. This, however, would dej^end 
upon the degree of tonicity with which the vagina "was endowed. 

" With regard to anteversion the case is even stronger, while at 
the same time it is simpler, for the anterior wall of the vagina is 
naturally tense, and its tension is usually heightened by the mere 
fact of the uterus being in a state of anteversion. In this tense 
condition of the anterior vaginal wall we have a marked contrast 
with the posterior wall ; the latter is much longer than a straight 
line drawn between its two extremities, and its lower end is con- 
nected with parts that are comparatively mobile ; the former is firmly 
attached to the pubic arch. By reason of this tension of the an- 
terior wall of the vagina, its virtual shortening occurs almost at once 
whenever any noteworthy pressure is made upon it : hence, any of 
the various forms of anteversion pessaries that are supposed to act 
by lifting the body of the uterus directly up, really accomplish its 
ascent by stretching the anterior wall of the vagina, and thus drag- 
ging the cervix forward. In proof of this statement, witness the 
insignificant size of the anterior projections of these instruments — 
projections utterly incapable of reaching to the height that they 
would have to reach in order to make direct pressure upon the body 
of the uterus, even with the bladder intervening, when the organ 
had approached anywhere near its normal position. The great sen- 
sitiveness of the anterior vaginal wall to pressure, the well-known 
hability of ulceration to occur upon it under the pressure of a pes- 
sary, both point to its greater tension as compared with the posterior 
wall. 

" Passing now to the third of the various methods of action that I 
have attributed to pessaries — that of traction upon the lower portion 
of the uterus — but little need be said about it, for the considerations 
brought forward to show the limited scope of the direct-pressure 



RETROVERSION OF THE UTERUS. 317 

tbeorv, all conspire to advance the traction theory to the most im- 
portant position. Such I believe it ought to occupy, unless the 
statements I have put forth are shown to be erroneous. I v^ill 
simply add that always in ante version, and usually in retroversion, it 
is through the medium of the vaginal wall, in my opinion, that pes- 
saries make traction upon the cervix. 

" I will briefly mention some of the practical applications of the 
doctrine I have sought to uphold. In cases of retroversion it is 
usually sufiicient if pessaries are to be used at all, to employ an in- 
strument simply with the idea of making backward pressure upon 
the posterior wall of the vagina, directing the pressure somew^hat 
upward, unless there are special reasons for not doing so, but not 
resorting to pessaries with such an exaggerated pelvic curve as to 
render their introduction difficult. If the instrument is curved 
rather sharply at a point very near its upper end, the pressure will 
be distributed more evenly over the posterior vault of the vagina, 
and, therefore, will be borne better. 

'' The usual forms of retroversion pessaries (the Hodge instrument 
and its various modiflcations, including those with external support) 
seem to me to act in this way, and 
to be as unobjectionable as any we 
are likely to hit upon. More or 
less stretching of the posterior 
vault of the vagina is apt to re- 
sult, but it is of little consequence 
€ven should it prove permanent, 
for it in no wise interferes with the p^^, i48.-Albert Smith pessary. 
natural functions of the parts. 

Broad pessaries, penetrating between the utero-sacral ligaments, 
should never be used, for these ligaments form a part of the mech- 
anism by which the normal situation and attitude of the uterus are 
maintained, and anything that stretches and relaxes them interferes 
with the permanent cure of retroversion." 

ADAPTATION OF PESSARIES. 

The adaptation of pessaries for the relief of reti^oversion, is facili- 
tated by keeping in mind the object to be accomplished, and the way 
in which the instrument acts in fulfilling these requirements. All 
that remains, then, is to shape the pessary to the case in hand, and 
to place it in position after the uterus has been restored to its place. 
This is an easy or difficult task, according to the artistic and me- 
chanical skill of the surgeon. Badly -adjusted pessaries are not so 




318 DISEASES or WOMEN". 

common as badlj-fitting shoes and clothes, because they are not so 
generally used. No one who is destitute of some knowledge and 
skill in mechanics, will ever succeed in the treatment of displace- 
ments of the uterus by means of mechanical supports. The gravest 
errors are committed every day by using pessaries without under- 
standing the principle of their action or the methods of adapting 
them. This lack of knowledge and of the required ability lead to 
the too frequent use of certain kinds of pessaries known by the 
names of their inventors. The prevailing idea being that a certain 
form of pessary recommended by some one in authority will answer 
for all cases, a sHght variation in size being all that is necessary. 
This is certainly a great mistake. The only pessary which can be 
of service is one that is correctly adjusted to the patient who is to 
wear it ; not a ready-made one with a distinguished name and repu- 
tation. An abundant experience, so far as seeing and treating many 
cases goes, and some practical knowledge of the mechanical art, en- 
ables me to say, that no two cases of displacement are alike, and, 
therefore, each one must be fitted with a pessary of the special form 
and size required. This really simplifies practice greatly, because it 
enables one to reject the vast number and variety of ready-made 
pessaries in the market, and to choose the simplest forms and adapt 
them according to certain principles and the requirements of cases. 
In the books there is no end to the number of instruments com- 
mended, and the directions to introduce and remove them are ample 
and sufficient, but there is a conspicuous absence of any definite and 
useful directions regarding the manner in which such instruments 
are to be fitted. 

In the simpler cases when the uterus can be restored to its posi- 
tion completely, and when thus restored the vaginal walls assume 
their normal shape, the pessary is easily adapted. The length of the 
vagina should be obtained from the posterior fornix to a point cor- 
responding to the upper end of the urethra, and the width of the 
vagina at that part indicated by a line bisecting the center of the 
cervix uteri should be taken. These measurements give the size of 
the pessary required in length and width, and are usually taken 
through a Sims' s speculum, with the patient on the left side. 

The longitudinal measurement is easily obtained by a sponge and 
holder (Fig. 149), which are carried up by the side of the cervix to 
the upper termination of the vagina, and there marking, with the 
finger resting on the stem of the sponge-holder, the point opposite 
the junction of the bladder and the urethra. The transverse meas- 
urement may be taken by sight, or, if the eye is not trained suffi- 



RETROVERSION OF THE UTERUS. 



319 



cientlj for this, by a pair of long dressing-forceps having a mark on 
the handles the same distance from the lock as the point of the 
blades. The for- 
ceps are passed up 
and the blades ex- 
panded until they 
reach the lateral 
walls of the vagina, 
and, while held in 
this position, the 
measurement is ob- 
tained from the ex- 
tent of separation 
of the handles. The 
size being obtained, 
the shape next de- 
mands attention. 
The outlines of the 
Albert Smith pes- 
sary (Fig. 148) are 
adapted to the lat- 
eral vaginal walls 
in a general way, 
and any change to 
suit special cases is 
easily made. The curves for the antero-posterior walls are slight 
modifications of the ogee curve of the mechanic, which is two seg- 
ments of a circle joined 
and reversed. This shape 
may be taken as a basis 
from which changes of 
form must be made in 
every instrument used. 

The guide for the form 
of these curves I have ob- 
tained in this way : I first 
ascertain by touch and in- 
spection the length of the 
invagination of the cer- 
vix posteriorly, and then 
make the posterior up- 
ward curve of the pessary a little short of the extent of this iu- 




FiG. 149. — The method of measuring the length of the pes- 
sary ; p, retracted perineal body. 



anterior 
Vd9final 




Fig. 150. — Diagram of pessary in situ on looking at 
it in Sims's position, through Sims's speculum. 



320 



DISEASES OF WOMEN. 




Fig. 151. — Slight invagination of cervix posteriorly 
with suitable pessary. 



vagination. The ante- 
rior downward curve 
is made about equal to 
the posterior, subject 
to slight variations to 
meet special cases. 

Figs. 151 and 152 
show two cases dif- 
fering in the extent 
of invagination, with 
pessaries adapted to 
them. 

These rules for the 
adaptation of pessaries 
are only useful as a 
basis to start from ; 
each case requires one 
deviation or more from 
these rules. This ne- 



cessitates a material for a pessary which is easily molded, and 
this is happily now afforded in the instrument made of whale- 
bone and fine copper-wire, and then covered with soft rubber. 
This kind of a pessary can be modeled with the greatest facility 
to any form. 

To restate briefly 
the most important 
points in the manage- 
ment of mechanical 
supports in the treat- 
ment of retroversion, 
I would say that my 
method is as follows : 
Sims's position and his 
speculum are used in 
replacing the uterus, 
and when it is restored 
the measurements are 
taken, a pessary se- 
lected of the proper 
size and modeled to 
suit as nearly as possi- ^ ^.^ t^ •, ^ • • .• c • . • i 

. '^ .' liG. 152. — Decided invagination or cervix posteriorly 

ble. It IS then mtro- fitted with a suitable pessary. 




RETROVERSION OF THE UTERUS. 321 

duced and careful observations made to see if it fulfills the require- 
ments. If it does not it is removed, altered, and reapplied, care 
being taken never to have the instrument large enough to make 
general pressure on the vaginal walls, nor of such shape that it will 
make undue pressure at anj one point. 

Where possible, I prefer to introduce and remove pessaries 
through Sims's speculum. The method of doing this is very sim- 
ple. In the introduction the perinagum is retracted, and the pessary 
turned up on the edge is passed beyond the vulva and then turned 
half round, which brings it into position. 

It is usually the case that, in the treatment of retroversion, the 
pessary requires to be changed in shape quite frequently during the 
first two or three weeks that it is in use, but with the material de- 
scribed this is easily done. When the uterus is well in place, and 
the vagina no longer appears to be undergoing any changes from 
involution and contraction, then a hard-rubber pessary is made, using 
the soft one, which has been made to answer the purpose, as a model. 
The hard rubber, of course, can be worn a much longer time than 
the soft, and is much more agreeable to the tissues. 

In regard to the modifications to be made in pessaries, to suit 
cases as they present themselves, all that is necessary will be said 
when giving the histories of cases. It is important, however, to 
keep in mind what has been said in regard to the cases in which the 
uterus can not be fully restored to its normal position, owing to 
changes in the posterior vaginal wall and the uterine ligaments. In 
such cases the restoration to the normal position must be gradual, 
and hence the use of the pessary is to keep the uterus in the posi- 
tion in which it is placed by the efforts at restoration, and by the 
support of the instrument to favor a tendency toward the normal 
position on the part of the uterus. In the management of such 
cases the posterior part of the pessary should 
not be much curved upward, if at all, be- 
cause the object is to have the pessary carry 
the posterior vaginal wall backward behind 
and below the uterus to support the body 
and fundus, while the cervix resting be- 
tween the bars of the pessary is unsupported 
and free to sink downward and backward Fm. 158.— What the pessary 
as the body of the uterus rises. Here the . ^°'' ''''^ ^^• 

principle of the lever acts to change the axis of the uterus. This 
is shown in Figs. 154 and 155. 

The lever action of the pessary is made more effective by the 
22 




322 



DISEASES OF WOMEN". 




vagf. 



pressure of tlie bladder and the anterior vaginal wall upon the ante- 
rior part of the instrument, which inclines to raise the posterior part 

upward, and so bring the pessa- 
ry into a more oblique position 
as the uterus rises. See Fig„ 
154. 

The pessary being wedge- 
shaped — that is, narrower in 
P?_^*'. if/~=^:^:LM>^'^^ M^^^j^ant. front than behind — is held up- 

^wlii ward by the contraction of the 
^^S9xi ^f lower portion of the vagina, 

Fig. 154.— How the pessary acts-shown by ^nd the wedffC-action helps the 
the arrows in the diagram. • p i 

lever-action of the pessary to 
raise tlie uterus and throw it forward. 

In regard to the surgical operations employed in the management 
of retroversion, I may say that, where the cervix uteri is lacerated, 
it should be restored, and also that the pelvic floor, if injured, must 
be operated upon in order to care retroversion. In fact, very little 
progress can be made in the treatment of retroversion, unless the 
pelvic floor and uterus are normal or nearly so. 

This is all the surgical treatment that I now employ, besides 
mechanical support, in the management of these displacements. 

In recent times, Alexander, of Liverpool, has 
devised a plan for the correction of uterine dis- 
placements, which consists in shortening the 
round ligaments. In his presentation of the 
subject, to the British Gynecological Society, 
he said that the operation has now been per- 
formed in nearly all prominent cities in the 
world, and by most operators with more uniform 
success than generally befell any new operation. 
He never found any difficulty in finding and 
drawing out the ligaments. An incision was 
to be made upward and outward from the pu- 
bic spine, in the direction of the inguinal canal, 
for one and a half to two or three inches, according to the fat- 
ness of the subject. A considerable thickness of subcutaneous fat 
was then met with, which must be cut tlu-ough by subsequent incis- 
ions, until the pearly, ghstening tendon of the external oblique 
muscle was reached. Midway through the fatty tissue an aponeu- 
rosis sometimes appeared, so firm and smooth, that it might cause 
the operator to think he was deep enough, but he would find no liga- 




FiG. 155. — Second step ; 
the uterus falls into 
the pessaiy. 



RETROYERSION OF THE UTERUS. 



323 



ments at this spot. The first stage of tlie operation consisted simply 
in cutting down upon the tendon of the external oblique muscle, 
until it appeared clean and shining at the bottom of the wound. 



nivi 

vfieiN/l 

BISTCnOCD, 




Fig. 156. 



-The knee-chest position — air enters the vulva, and distends the vagina, and 
the fundus falls in the direction of the arrow. 



The external ring was then found. The finger passed to the bottom 
of the wound detected the spine and the ring outside. Having iso- 
lated the externah wound, and tied any little vessels, the next step 
was to find the end of the ligament, ^j everting all the structures 
upward, the round ligament could be seen, generally at the lowest 
part, and with the white easily distinguished genital branch of the 
genito-crural nerve along its anterior surface and close to it. The 
ligament at this stage was more or less rounded in shape. It was an 
easily recognized flesh-colored structure. When the ligament was 
identified, the small nerve on its surface was to be cut through 
without dividing any of the ligament. Then gentle traction was to 
be made, either by the fingers or by broad, blunt-pointed forceps. 
Bands holding it to neighboring structures were cut through with 
scissors. As soon as it began to peel out, it was left, and the oppo- 
site side begun. The final stage of the operation consisted in placing 
the uterus in position by the sound, and pulling out the ligaments 
until they were felt to control that position. A curved threaded 
needle, with fine catgut, was used to stitch each ligament to both 
pillars of the ring and the external abdominal ring was closed with- 
out strangulating the ligament as it lay between them. The ends of 
the ligaments were now cut off, and the remainder stitclied into the 
wound by means of the sutures that closed the incision. A fine 
drainage-tube was inserted, and the wound washed out with carbolic 
or other lotion before these sutures were tied. 



324: DISEASES OF WOMEN. 

The after treatment consisted in rest. The tubes were renioved 
on the second day, when the wound was di-essed. The mortality of 
the operation might be set down as nothing. Three deaths had oc- 
curred, but they were due to preventable causes. As mortality did 
not seriously enter into any consideration of the results of this opera- 
tion, the real question at issue was whether it fulfilled the intentions 
of the operator and satisfied the expectations of the patient. The 
operation was designed to correct certain uterine displacements, and 
these alone. Whether the discomfort of the patient would be there- 
by reheved, entirely depended on whether or not the symptoms were 
due to the displacement. To secure success, the operation must be 
properly performed, and the after treatment must be rational, so that 
no strain might be placed on the ligaments until sound union had 
taken place. 

Most excellent results from this operation have been reported by 
many surgeons. I have not practiced it, for the reason that the 
cases which are curable by Alexander's operation are curable by the 
means which I have described, and the cases that are incurable by 
such means are also incurable by Alexander's operation. 

Further experience, however, may prove that the shortening of 
the round ligaments will cure retroversion more ^promptly and per- 
manently than any other method of treatment, but up to the present 
time that question is not fully settled.- 

Retroversion with fixation of the uterus from adhesions has been 
considered incurable in times past. The use of electricity, massage, 
and absorbents, such as iodine and ichthyol, frees the uterus from 
adhesions so that it can be replaced. Recently some valuable con- 
tributions have been made on this subject. Such cases have been 
treated by laparotomy, breaking up the adhesions and restoring the 
uterus to its place. 

Prof. W. M. Polk has given the results of his labors in this field, 
in a most valuable paper, published in the " American Journal of 
Obstetrics," for June, 1887, from which I make the following quo- 
tations : 

"Laparotomy for adherent retroflexed or retroverted uterus. 
A. W., aged thirty-eight. This patient has suffered from pelvic 
pain for several years. The originating cause was obscure, but it 
seemed to have been due to pelvic inflammation, induced by treat- 
ment for posterior displacement of the uterus. Examination showed 
that the uterus was retroverted and bound down. Sensitive masses 
were discovered on both sides of the uterus in the broad ligament 
regions. Upon opening ♦the abdomen, the remains of pelvic peri- 



RETROVERSION OF THE UTERUS. 325 

touitis were evident. The uterus was fixed in the cul-de-sac. 
Chronic salpingitis and periovaritis were present on both sides, the 
tubes and ovaries being attached to the posterior face of the broad 
ligaments, but not to the pelvic floor. 

" The adhesions binding down the uterus were separated and the 
tube and ovary upon the left side removed, after which the mass 
npon that side could no longer be felt. The appendages upon the 
right side were not disturbed, owing to the accidental wounding of 
a vessel close to the uterus. There was prolonged and very trouble- 
some bleeding. By the time this was controlled I did not think it 
wise to further prolong the operation, the patient's condition forbid- 
ding it. This case afforded me an opportunity to study the behavior 
of an inflamed tube after the adhesions binding it down and crip- 
pling it had been torn up. I carefully freed the right tube and 
ovary from the adhesions binding them to the posterior face of the 
broad ligament^ and satisfied myself that they, as well as the append- 
ages on the left, represented the mass felt in this region through the 
vagina. I used a drainage-tube, as there had been a good deal of 
manipulation in the pelvis. This served the additional purpose of 
keeping the uterus forward 

" The patient remained in the hospital nearly two months, and 
when I examined her just before her departure I found both sides 
of the uterus free from the masses, and from sensitiveness as well. 

" Mrs. A., aged twenty-six. Seven years ago had a severe at- 
tack of pelvic inflammation ; she was very ill for three months, and 
then made a gradual recovery. The prominent local condition dur- 
ing the attack was a mass in the left iliac region. This slowly dis- 
appeared, but ever since the illness she has been conscious of uneasi- 
ness in that region. From the date of the inflammatery attack to 
the present, she has suffered severe dysmenorrhcea, this pain lasting, 
as a rule, for three days, and of sufficient intensity to compel her to 
keep in a recumbent posture during its continuance. Aside from 
this menstrual pain, the soreness in the left iliac region, and an occa- 
sional attack of rhematism, she has been in good health. 

" Two months ago she was married, since which she has been a 
constant sufferer from pelvic pain, with much increase in the dys- 
menorrhoea. Upon examination, I found the uterus retroflexed and 
firmly bound in Douglas's cul-de-sac / the body enlarged and very 
sensitive. Upon the left side, in the broad ligament region, there 
was a fixed sensitive mass, about as large as a walnut ; upon the right, 
in the corresponding region, a similar but smaller mass was likewise 
detected. 



326 DISEASES OF WOMEN. 

" Diagnosis. — ^Retroflexed, adherent uterus, with adherent tubes 
and ovaries ; the whole the result of a prior salpingitis and peritoni 
tis. I advised laparotomy, and in March it was done. The ad- 
hesions binding the uterus, tubes, and ovaries were easily broken up 
and those organs liberated. The tube walls were somewhat thickened, 
but there was no distention of the cavities. The right ovary was 
small, the left somewhat enlarged ; this one was much more firmly 
and extensively adherent than the right. A drainage-tube was 
placed in position, as usual, behind the uterus, and the wound was 
closed. The patient made a good recovery, and has had one men- 
struation free of pain. 

" The uterus, to-day, is in normal position, with the exception that 
it is somewhat lower in the pelvis than I would prefer. It is now 
movable, and it, together with the appendages, is as free from pain 
on pressm-e as could be possible so soon after operation." 

Massage. — Massage, as performed by Brandt, is of great value in 
the treatment of backward displacements of the uterus complicated 
with adhesions. 

The favorite method of some surgeons of the present day is to 
perform laparotomy and then divide the adhesions ; but there is a 
great liability for these to reform and render the operation useless. 
When relief is obtained by massage, it is permanent, as a rule. 

In such cases Brandt begins by performing massage on the gan- 
glia and lymphatic vessels in the neighborhood of the promontory 
of the sacrum, in order to empty them of the lymph which they 
contain, and thus make a demand upon the lymphatics for material 
for absorption. Then he carries his hand above the periphery of 
the adhesions, in order to empty the efferent vessels, which are thus 
prepared to receive the lymph coming from the center. The direct 
massage of the adhesions which bind the uterus backward is per- 
formed in the same manner as the bimanual examination. Under 
these circumstances Brandt advises massage of the adhesions from 
before backward with the left hand, while the right index-finger in 
the rectum sustains them. In many cases this can be done just as 
w^ell, in my opinion, per vaginam. 

This method of Brandt achieves excellent results in a short time, 
even in cases of old exudates whose disappearance causes the com- 
pression of nerves and the consequent pain to cease. The mechan- 
ical action of massage combats pain and modifies temperature, and 
is therefore both analgesic and antiphlogistic. 

Bimanual massage, according to Brandt's method, is best adapted 
to broad adhesions and the excessive inflammatory exudations of 



RETROVERSION OF THE UTERUS. 327 

pelvic peritonitis and cellulitis. Where these are reduced, and in 
cases that from the first present cord-hke peritoneal adhesions, 
stretching should be practiced. I do not mean the forcible and 
rapid breaking up of these adhesions, but a repeated, methodical 
traction upon the adhesion bands, by grasping the uterus bimanu- 
allj, and, while trying to replace it and holding the adhesions on 
the stretch, moving the uterus up and down. As soon as the uterus 
can be brought into or toward its normal jDOsition, efforts should be 
made to retain it, first by tampon, and finally by a pessary adapted 
as described at page 312. 

Hysterorrhaphy. — Hysterorrhaphy is the name given by Howard 
A. Kelly to the operation of fixing the fundus uteri to the abdominal 
wall ; it is also known as ventro-fixation of the uterus. It has been 
found to be efiicient in cases of backward displacement of the uterus 
with adhesions which do not yield to other methods of treatment. 

This procedure is not in accord with the highest principles of 
surgery ; to produce one pathological condition in order to relieve 
another is always objectionable, and should be avoided if possible. 

Relief follows this operation in some cases, but in these it will 
usually be found that, after some months, the uterus has broken 
away from its attachment to the abdominal wall and has regained its 
normal mobility. 

In some cases the displacement will recur, while in others the 
patient will remain well. When the latter results are obtained, it is 
perhaps because the fixation remained long enough to permit the 
supports of the uterus to regain their normal state and keep the 
uterus in place after the fixation to the abdomen had ceased. 

The operation is performed as follows : An incision is made just 
above the pubes suflficient to admit two fingers. The adhesions are 
broken up by the fingers, and the fundus uteri is gently drawn up to 
the incision ; a Peaslee needle threaded with silk, catgut, or silk-worm 
gut, according to the choice of the operator, is passed through the 
abdominal wall, then through one horn of the uterus, and back 
through the abdominal wall again. This is repeated on the other 
side, and the sutures are tied. Some surgeons prefer not to include 
the fundus uteri, but to pass the sutures beneath the round or ovarian 
ligaments. In order to obtain firm union of the opposing surfaces, 
the uterine and parietal periton}\3um is partially vivified by scraping. 
I consider this unnecessary. 

The abdomen is afterward closed in the usual manner. If free 
haemorrhage follows the separation of the adhesions, it should be 
controlled by pressure with hot sponges. 



328 DISEASES OF WOMEN. 



RETROFLEXION OF THE UTERUS. 

In the chapter on anteflexion of the uterus the pathology of 
flexions generally was discussed, and the classiflcation adopted was 
that flexion was a deformity and not a simple dislocation. In fact, 
a very broad distinction was made between displacements and flex- 
ions. It was observed at the same time, that retroflexion of the uterus 
was frequently, in fact in the great majority of cases, produced as a 
result of a retroversion. The uterus tirst becomes displaced back- 
ward, and, in consequence of the deranged forces acting upon the 
uterus, it becomes bent upon itself — that is, flexed as well as dis- 
placed. Owing to this close association of retroversion and retro- 
flexion, and the fact that the treatment of both has much in com- 
mon, I have placed them together. 

In practice I have made out two degrees of retroflexion, and the 
flexion is confined to the body, the cervix maintaining its normal 

relations to the vagina. 
At all events the cer- 
vix is never bent back- 
ward. 

Pathology. — This 
is the same as in ante- 
flexion, so far as the 
uterus is concerned. 
There is a want of 
sufiicient tissue at the 
junction of the cervix 
and body of the uterus, 
the point where the 
flexion occurs. In the 
majority of cases the 
cervix and upper part 
of the vagina are 
farther forward in the 
pelvis than they should 
be, and the cervix 
points forward more than it should, but less so than in retroversion. 
This gives rise to a little shortening of the anterior vaginal wall, or 
else an undue invagination of the anterior wall of the cervix. 

Symptomatology. — The symptoms present in retroflexion are very 
much the same as those of retroversion, hence it is only necessary 
here to note some few that are more marked in flexion than in 



k 




Fig, 157.— Fibroid on posterior wall of uterus simulating 
retroflexion. 



KETROVERSION OF THE UTERUS. 



329 



version. In retroflexion the menstrual function is more frequently 
disturbed. Dysmenorrhoea is often present, and although the pains 
are less acute than in anteflexion, they are far more marked than 
in retroversion. In many of those having retroflexion the men- 
strual discharge is often quite offensive; this also occurs in other 
conditions, but, taken in connection with other signs and symptoms, 
it is valuable as a means of diagnosis in this affection. 

Physical Signs. — The points of difference between retroflexion 
and retroversion are, as observed by the touch, that the cervix in 
flexion does not point toward the vulva or pubes, but is nearly in its 
normal position. There is less relaxation of structure of the upper 
portion of the vagina. Behind the cervix the rounded fundus can 
be felt by the examining flnger to be pointing downward and back- 
ward, instead of directly backward as in retroversion. Between the 
cervix in the vagina and the fundus uteri the angle of flexion can 
be felt. All this can be made out by the vaginal touch, and, in 
favorable cases, the 
bimanual examination 
will help to verify 
the signs obtained. 

When the abdom- 
inal muscles are very 
lax and the vagina 
long and elastic the 
uterus can be carried 
upward with the fln- 
ger which is in the 
vagina, and brought 
within reach of the 
hand on the abdomen 
— i. e., the uterus can 
be grasped and exam- 
ined bi manually. In 
that case the defor- 
mity of the uterus can 
be clearly made out; 
but it is rare that this 

is practicable. It is usually impossible to reach the anterior wall 
of the uterus by the hand placed upon the abdominal muscles. In 
the great majority of cases I have been obliged to depend upon the 
vaginal touch and the uterine sound to make a positive diagnosis. 

The two conditions which I have found simulating the physical 




Fig. 158. 



Prolapsed and adherent ovary simulating retro- 
flexion. 



330 DISEASES OF WOMEN^. 

signs are a large and prolapsed ovary and a subperitoneal fibroma 
on the posterior wall of the uterus. These are shown in Figs. 157 
and 158. 

In either of these affections the touch gives the signs of retro- 
flexion, and it is only by using the sound and proving that the 
uterus is in its proper position and form that they can be distin- 
guished from flexion. While the sound is not absolutely necessary 
to differentiate between retroflexion and such conditions as those 
named, I find that it gives confidence in the diagnosis in retroflexion 
to pass it and see that the canal runs backward and is not distorted 
by the flexion. 

Sometimes it is very difficult to pass the sound around the 
point of flexion, and in order to do so it may be necessary to raise 
up the fundus and also tiie cervix, in order to straighten the canal. 
When the uterus is very tender, much care should be exercised in 
using the sound. The application of cocaine is useful in relieving 
the hypersesthesia. 

Causation. — Retroflexion occurs in single women, and also in 
those who have borne children. In the former, I have foimd it 
much more frequently. For practical purposes, this affection might 
be divided as regards causation into two forms, congenital and ac- 
quired. From the history of those cases in which this flexion is 
found in early life, I believe that it is brought about by some 
lesion of development. It may not be, strictly speaking, a con- 
genital malformation. It is more likely that the infantile uterus 
becomes retroverted before puberty, and then when secondary 
development takes place, the increase in weight of the body and 
fundus causes displacement of the upper part of the uterus, and 
the cervix being held in place by the resistant vagina, the flexion 
is produced. This is the only explanation of the production of 
these cases at puberty. When it is acquired after bearing chil- 
dren, I believe that retroversion occurs first, and if the cervix 
meets resistance from the anterior vaginal wall and bladder in 
front, the flexion is produced. If the uterus is made to bend a 
little at the point of flexion, the pressure at that point will cause 
atrophy at that point, and thereby the flexion will gradually in- 
crease. 

It is possible that in some of the acquired cases there is some 
lesion or excess of involution at the junction of the body and cer- 
vix, and the walls of the uterus being thus weakened at that point, 
permit the uterus to fall over backward. 

Prognosis. — In acquired cases, and uncomplicated, appropriate 



EETROVERSION OF THE UTERUS. 



331 



treatment wiJl usually give relief if persisted in long enough. In 
the so-called congenital forms, there will be found cases, which do 
not yield to treatment. Relief from the most distressing symptoms 
may be obtained, but as soon as the mechanical support is removed 
the flexion will return. The resistance of some cases to treatment 
I have found due to a rigid state of the posterior wall of the va- 
gina, which prevents the use of a pessary which would extend far 
enough back to throw the fundus forward. In such cases the use of 
a pessary often aggravates the trouble. 

Treatment. — The principles of treatment in retroflexion are the 
same as in retroversion, and hence need not be discussed here, fur- 
ther than to note some of the additional means necessary in flexion. 

To restore the uterus to its normal form and position it is often 
necessary to use the Elliott adjuster, and to repeat its use a number 
of times ; tlien a pessary should be employed as in retroversion. Jn 
adjusting the pessary, care should be taken not to curve the poste- 
rior bar too much, but to shape it so that it will carry the posterior 
vaginal wall back behind the body and fundus so as to support both. 
This can be made clear, perhaps, by showing the effect oi a pessary 
which is not of proper shape, and which increases the flexion by 
making pressure upward in place of backward (Fig. 153). 

Alexander's operation is suggested to the mind by those cases 
which do not yield readily to treat- 
ment, and I presume it would be use- 
ful. However, the only cases which 
resist the usual treatment are those 
in which the posterior vaginal wall 
is unyielding, and the uterus can not 
be straightened by Elliott's adjuster. 
In such cases there is reason to sup- 
pose that the uterus is flxed in its 
malposition by some old cellulitis or 
peritonitis ; and if so, Alexander's 
operation would not succeed. 

It is rather rare that the treat- 
ment prescribed fails. In obstinate 
eases in which the frequent straightening of the uterus does not 
stimulate the growth of tissue at the point of flexion, the stem 
pessary should be tried. 

The canal of the cervix should be dilated sufiiciently to admit a 
fair-sized glass or hard-rubber stem. The stem is then introduced 
to overcome the flexion and keep the uterus straight, and the pessary 




(after pi 



332 



DISEASES OF WOMEN. 



is used to keep the stem in place. The same kind of stem and 
pessary as are used in the treatment of anteflexion are employed, 
with this difference, that the pessary is adapted to keep the uterus 
in position as well as to hold the stem in place. 

To recapitulate, the stem corrects the flexion, and the pessary 
corrects the retroversion, as well as keeping the stem in place. 

Atrophy of the Uterine Walls at the Junction of the Body and Cer- 
vix. — This is a condition which 
causes anteflexion and retroflexion, 
which may alternate by turning the 
body of the uterus backward or for- 
ward. 1 have found it in those who 
have borne children, and also in 
those who have not. 

Pathology. — There is a defect in 
the middle layer of the anterior and 
posterior walls of the uterus at the 
internal os which permits the uterus 
to bend forward or backward with 
equal facility. Fig. 160 shows the 
appearance of such a uterus. Such 
cases are rare, and have a clinical 
history very much the same as ante- 
flexion. I can give the best descrip- 
tion of the affection by relating the history of a well-marked case. 



i 




posteriorlip 



anterior] 



Fig. 160. — Uterus with defective walls ; 
the supra-vaginal portion of the cer- 
vix is elongated (after Winckel). 



ILLUSTRATIVE CASE. 



A dressmaker, single, and in fair general health, twenty-seven 
years old, came under my care in the hospital, giving the following 
history : She began to menstruate at' fifteen, and from that time 
until she entered the hospital, had suffered from dysmenorrhoea. 
The pain at her periods became progressively worse, until she was 
entirely unfitted for her duties. 

She sought relief in medicine, but only large doses of opium 
sufficed. Becoming wholly useless, she entered one of the hospitals 
of this city, and remained under treatment there for four months. 
During that time she had violent hysterical convulsions at her men- 
strual periods, and deriving no benefit from treatment was dismissed 
as incurable. Upon examination, I found marked anteflexion of 
the body of the uterus ; and, owing to slight stricture of the internal 
OS and the extreme tenderness of the uteinis, the sound could not 
be passed until she was anaesthetized. I then found that the os 



RETROVERSION OF THE UTERUS. 333 

internum was constricted. I incised it and dilated until I could 
pass a 1^0. 9 English sound. At the same time I used Elliott's ad- 
juster to straighten the uterus, and carried the fundus backward. 
This was accomplished with unusual facility, the uterus making no 
resistance to bending in any direction. The instrument was with- 
drawn, and the patient placed in bed to rest; there was no pain 
or inflammation following this treatment. Three days afterward I 
made a digital examination, and found the uterus retroflexed. By 
using again the Elliott adjuster I was able to change the retroflex- 
ion back to the original anteflexion, which remained so for several 
days. It being necessary to pass the sound every third day to pre- 
vent the recurrence of the stricture at the internal os, I took advan- 
tage of the opportunity, by changing the flexion a number of times, 
and found that whatever position I placed the body of the uterus in, 
it would remain there. 

The dilatation of the os externum gave the patient great relief 
from the dysmenorrhoea. The usual treatment for congestion and 
hyperaesthesia was continued, and the canal kept dilated by the use 
of the sounds. A stem pessary was tried, but she could not tolerate 
it except by keeping in bed. She improved so much in two months 
that she left the hospital, and only returned occasionally as an out- 
patient. For two years I kept her under observation and, although 
she was not entirely free from pain, she was able to make her living. 

In this case I feel sure that the trouble originated in an imper- 
fect growth at the time of secondary development. 

In one other case of which I have full notes, the flexion came 
after the patient's second confinement, and, perhaps, was due to a 
derangement of involution. 



CHAPTER XIX. 



ABUSE OF PESSARIES. 



Injuries to the Pelvic Organs Caused by the Improper Use of 
Pessaries. — The dangers of stem pessaries have already been referred 
to in the chapter on flexions, so* far as their liability to cause acute 
inflammations of the uterus, pelvic cellular tissue, and peritonseum. 
There are still other injuries which they may give rise to. When 
the stem is small and badly adjusted with reference to the character 
of the flexion, the point of the instrument may become imbedded in 
the wall of the uterus, or the lower part of the stem may divide the 
posterior wall of the cervix. Both of these injuries I have seen in 
practice. 

In one case, an anteflexion of the cervix, a small stem of steel with 
a hard-rubber disk at its end was introduced by a general practi- 
tioner, and left in place for three months. 
The patient soon began to suffer from a 
purulent discharge, which gradually in- 
creased, and there was much pain, greatly 
aggravated by walking. When I saw her 
the relations of the stem and uterus were 
as shown in Fig. 161. After the removal 
of the stem, the cervix presented exactly 
the same appearance as that seen after 
Sims's operation for flexion, except that 
there was more thickening of the edges of 
the wound and more inflammation than I 
have ever before seen after disci sion of the 
cervix by the surgeon. The inflammation 
subsided under ordinary treatment, and she 
was at least none the worse for having worn the stem. 

Another patient came under my observation while wearing a stem 
pessary, which had been introduced six weeks before by her medical 




-Stem of pessary ul- 
cerating through cervix. 



ABUSE OF PESSARIES. 335 

attendant. She had suffered pain and tenderness from the time that 
the stem was introduced, and for a week before she came under my 
care the suffering was so great that she was obliged to stay in bed 
and take opium freely ; she had also a purulent discharge, and at 
times bleeding. The stem was about the thickness of a ]^o. 9 
catheter. It was made of hard rubber, and was held in place by a 
cup pessary in the vagina. While the stem was still in place (the 
vaginal pessary having been removed) the body of the uterus was 
found to be markedly anteiiexed, and its anterior wall near the 
fundus was unusually prominent, as if it contained a small fibroid 
tumor. 

The flexed shape of the uterus led me to suppose that the stem 
must be curved, but on removal it proved to be straight. 

I then passed with some difficulty, owing to the tenderness of 
the uterus, a much-curved sound into the cavity of the uterus, and 
then after straightening the sound, it was passed into the groove 
made in the posterior wall by the stem. One might suppose that 
the cavity of the uterus was simplj^ dilated 
so that the sound could be curved forward 
and then straightened and passed along the 
posterior wall, but I am confident that such 
was not the case. The posterior wall of the 
body was flexed forward and rested upon 
the anterior wall on either side, and the sul- 
cus made by the stem was in the center. 

Fig. 162 shows the conditions as they ap- 
peared to me during my examination. 

There was considerable bleeding after 
the removal of the steni, and the uterus be- ^ 
came more flexed apparently as soon as the ^th;ough7o%''of Serus^ 
support was withdrawn. There was relief 

from the acute symptoms and inflammation caused by the instru- 
ment, but the dysmenorrhoea was worse than before. 

Atrophy of the muscular tissue of the vaginal walls from over- 
distention by pessaries that are too large is quite frequently seen. 
Practitioners who are not skilled in the use of pessaries, yet never- 
theless use them, produce this injury of the structures of the vagina. 
The same unfortunate results are effected by those who believe in 
the theory that in order to keep the uterus in place, in retroversion, 
for example, it is necessary to use a pessary large enough and suf- 
ficiently curved to force the posterior wall of the vagina fai- up in 
the pelvis above its normal elevation. 




336 



DISEASES OF WOMEK 



The following case will illustrate this : The patient had children, 
and was said to have had a displacement; probably retroversion. 
She was treated with a variety of pessaries, so she told me, but did 
not get well ; when she came to me, she had much backache, pelvic 
pain, and vaginal leucorrhoea ; she was then wearing a pessary nearly 
large enough to fill the pelvis, and much curved both in front and 
behind. 

The uterus was in about its proper place in the pelvis, but the 
vagina was greatly overdistended and its walls were thin, especially 
the posterior wall behind the cervix. On removing the pessary, a 

difficult task owing to its 
size, the vaginal wall, and 
the rectal wall also, I think, 
fell downward and formed 
a rectocele high up. 

Fig. 163 will give an 
idea of the state of the parts 
as they appeared to the 
touch, after the pessary was 
removed. 

The part of the thin wall 
of the vagina bulged down- 
ward, and felt to the touch 
exactly like the ordinary 
rectocele, except that the 
protruding mass was at the 
upper part of the vagina in- 
stead of the lower; when seen through the speculum introduced 
about an inch and a half, this was confirmed by the eye. 

The first impression obtained by the touch was that of a portion 
of intestine distended with gas lying behind and below the cervix 
uteri. The patient felt a little more distress, strange to say, after 
the pessary was removed ; when she tried to walk without it, she 
suffered from pain and tenesmus very severely. This I have found 
to be the case in all instances of overdistention of the vagina; 
patients suffer with tlie support, and for a few days suffer more 
without it. 

This is much the same experience as ladies have who can not go 
without corsets, and the tighter they lace them and the more damage 
they do, the more they miss them when they discontinue their use. 
This patient was kept rather quiet for a time, and astringent in- 
jections were used, which, after a long time, restored the vagina more 




-High rectocele due to improper pes- 
sary. 



ABUSE OF PESSARIES. 337 

nearly to its normal calibei*. There remained for over a year, when 
I last saw her, and perhaps ever since, a sagging of the upper part 
of the posterior vaginal wall. 

Another case, somewhat of the same character, came to me from 
the West. She was forty, and single ; her health and strength had 
been good until she was thirty-six years of age, when she began to 
have a variety of nervous symptoms clearly due to general debility. 
She was treated by several reputable physicians, but not recovering 
as fast as she desired, she consulted still another, who told her that 
she had falling of the womb, which caused all her troubles. There 
was not a symptom that pointed to any disease or displacement of 
the sexual organs, but a Cutter pessary was introduced and the 
patient wore it about two years. Her general health improved very 
little, and the pessary soon caused her trouble ; still she persisted in 
wearing it because the doctor said she must do so ; her condition be- 
came so wretched that she came East, in the hope of gaining relief. 

When she came to me she had some vaginitis and vulvitis 
caused by the pessary, but the uterus was perfectly normal in every 
way. The Cutter pessary had pushed up the posterior vaginal wall 
far beyond tlie cervix, which lay on one side of the instrument, not 
between the bars as it should have done. 

The condition of the posterior vaginal wall at the upper part was 
about the same as in the case just related. The lower part of the 
vagina was normal, excepting the inflammation caused by the pes- 
sary. The vulva was also inflamed, and she suffered greatly from 
this, especially in taking exercise. This patient also felt the want of 
the pessary when it was removed, but only for a short time. She 
was examined seven months after the removal of the instrument and 
was found to be perfectly well. 

Injury of the Posterior Vaginal Wall by the use of Pessaries in 
Cases of Incurable Retroversion. — This case illustrates a class which, 
though not large, deserves notice. In retroversion with fixation of 
the uterus, either from a congenital state or because of adhesions or 
shortening of the post-uterine ligaments, there is sometimes a slight 
mobility of the uterus which admits of its being partly restored. 
This leads the practitioner to hope that, by the use of the pessary, 
the displacement can be corrected. The result is that the posterior 
portion of the pessary makes too great pressure upon the vaginal 
wall and produces inflammation and abrasion. This usually causes 
a free vaginal discharge and pain enough to make the patient seek 
relief before much permanent injury is done. In all such cases pes- 
saries should not be used at all, but if one is employed in the hope 
23 



338 DISEASES OF WOMEN. 

of doing good, it should be abandoned as soon as it causes anv irri- 
tation. 

In these incurable cases, a slight relief may sometimes be given 
by using a Peaslee's ring, or a Smith's pessary very little if at all 
curved posteriorly. Either of these instruments will hold the uterus 
a trifle higher in the pelvis, and this will, in some cases, give a sense 
of support and relief to the patient. 

Overdistention and Atrophy of the Anterior Vaginal Wall from 
the use of Anteversion Pessaries. — This condition is rarely seen ex- 
cept among the patients of those who look upon anteversion as a 
morbid state of importance whenever it occurs. 

In order to raise the body of the uterus up when it is anteverted, 
it is necessary to elevate the anterior vaginal wall far beyond its 
normal position. In order to do this, the instrument must make 
well-marked pressure upon the parts, and, if this is continued, the 
muscular wall becomes atrophied and overdistended, and this can 
be carried on to a very great degree, the whole length of the vagi- 
nal wall becoming double that which it originally was. 

When the pessary is removed in such a condition, there is at 
once observed a well-defined and large prolapsus of the vaginal wall, 
and if the instrument is left out, cystocele will soon follow. This 
is the rule, but the final results depend to some extent upon the 
length of time that the pessary has been worn. 

The stretching of the vaginal walls caused by pessaries can be 
overcome by removing the instrument, and prescribing rest and 
astringent injections. But if the overdistention has been kept up 
long enough to cause atrophy of the muscular tissue, the injury is 
permanent and can be very little improved by treatment. 

There is also danger to the bladder and urethra from the ante- 
version pessary. The following case will show how this comes about : 

Frequent Urination associated with Slight Anteversion of the Blad- 
der. — The lady was about thirty, and had a child seven years old. 
She gradually developed a pelvic tenesmus and some irritability of 
the bladder. She consulted her physician, who diagnosticated ante- 
version of the uterus, and stated that the disturbed function of the 
bladder was due to the malposition of the uterus. Thomas's ante- 
version pessary was introduced by the physician in charge ; this 
gave the patient a sense of support which was agreeable, but more 
disturbance of the bladder was caused. The physician urged the 
patient to wear the pessary, telling her that she would get used to 
it, and the unfavorable effects would pass off ; but this proved not 
to be the fact. The patient then came under my care, having worn 



ABUSE OF PESSAEIES. 



the pessary for two weeks ; I at once removed it, with the result of 
giving some relief, but there was still more impatience of the blad- 
der than before the instrument was used at all. The true state of 
aifairs proved to be that the patient had a slight catarrh at the neck 
of the bladder, not due to the malposition of the uterus at all, and 
the pessary only increased the original affection. 

In proof of this, the symptoms all disappeared when the disease 
of the bladder was removed, and without changing the position of 
the uterus in the least. 

Cup Pessary with an Extra- Vaginal Support, causing Vulvitis and 
TJlceration of the Vagina. — All the pessaries having a stem attached 
to a band around the body have given trouble when worn for any 
length of time. The evil caused by the one used in this case, is 
typical of most of them. 

The patient lived in the country, and, while suifering from pel- 
vic tenesmus, called in a physician who adjusted a Babcock's uterine 
sup23orter for " falling of the womb." She was directed to remove 
it at night and introduce it 
in the morning. For a short 
time she felt some relief, 
but soon began to suffer 
from a profuse vaginal dis- 
charge and great tenderness 
about the vulva. The suf- 
fering increased until she 
was unable to walk, and the 
introduction of the support- 
er gave great pain. 

When I examined her I 
found the relations of the 
uterus and supporter as rep- 
resented in Fig. 164:. The 
uterus was retro verted and 
the cup and stem were situ- 
ated in front of the cervix 
and held the anterior vaginal wall high above its normal position. 
There was some ulceration of the vaginal wall and general vaginitis 
and vulvitis. 

The apparatus was removed, vaginal injections of borax and 
water employed, and in a short time the inflammation was relieved. 
The uterus was then restored to its normal position, and retained 
there with a pessary such as I use in such cases, and she did very 




Fig. 



164. — Displacement caused by a badly adjusted 
pessary. 



340 DISEASES OE VTOMEX. 

^ell. But for several montlis there Tvas a tendencv to prolapsus 
of tlie anterior vaginal wall, owing to the overstretching of it bv 
her former stipponer. 

The Upper Rim of a Cup Pessary partially imbedded in the Vagina, 
around the Cervix Uteri. — This patient had a prolapsus uteri, and 
the physician who had her in care tised a cup and stem of soft nib- 
ber ; the ctip was Cjuite a large one and its edges were rather sharp. 
I think it was called the Barrington stipporter. She was much re- 
lieved by this instrument, being able to do her duty as a laundi-ess, 
btit she began to have a vaginal discharge and occasional bleeding, 
with pain and tenderness. I saw her with the doctor and found a 
ring of raw tissue in the vagina, arotind the cervix titeri. correspond- 
ing to the size and shape of the cup. 

The uterus was large, measuring nearly five inches. Evidently 
the pressm-e upon the instrtiment was more than the tissues of the 
vagina cotild stand. The patient rested for a time and used vagi- 
nal injections ; the parts healed promptly, but the scar tissue re- 
mained tender, and gave way under the pressure of the instrument, 
whenever she wore it for any length of time. 

I think that this patient could have been cured by rest in the 
recumbent position until the enlargement of the uterus and relax- 
ation of the vagina had been overcome, and then the pelvic floor 
restored. But she could nut give the time to this, being poor, and 
obliged to work to live. She was directed to wear a perineal pad 
fastened to a waist-belt, and she got along fairly well in that way. 

A Pessary imbedded in the Posterior Vaginal Wall. — In the cur- 
rent literature there have been many extraordinary cases recorded of 
pessaries having passed through the vaginal walls into the rectum 
and bladder. Some of these cases have been very remarkable, and 
have been recorded as matters of cirriosity. Little has been said 
about the causes of such accidents or how to manage them. 

The following case illustrates the most common forms of this ac- 
cident : The patient was a widow who had borne several children, 
and had been well until the menopause, when she became insane. 
At the outset of her mental derangement, her physician suspected 
that she had some uterine disease, and. on investigating the case, 
foimd the uterus larger than it ought to be and retroverted. He 
restored the organ to its normal position and introduced a pessary 
which held it there : the instrument was well adapted and answered 
the purpose well. After this his attention was wholly directed to 
her mental condition, and she recovered her mind in about one year. 
The pessary was forgotten by her physician, who introduced it 



ABUSE OF PESSARIES. 341 

while she was in the asylum. When she came home, or soon after, 
she began to have a discharge from the vagina and occasional bleed- 
ing. I then was called to examine her, and found all that portion 
of the pessary which rested behind the cervix uteri, imbedded in the 
vaginal wall. The tissues to the extent of nearly a quarter of an 
inch had united in front of the pessary bar. 

Traction was made upon the pessary until the tissues inclosing it 
were made tense, and they were then divided down to the instru- 
ment ; there was much bleeding, but the parts healed well, leaving a 
large scar in the posterior vaginal wall. 

This case is one the like of which is not infrequently seen ; they 
differ from most of those already mentioned, in the important fact 
that they occur in cases in which the instrument is well adjusted and 
answers its purpose for a time, causing no trouble until the vagina 
begins to contract during the final involution at the menopause. 

The vagina contracts so much that the pessary, which, at the 
time of its introduction was small enough and had plenty of room, 
becomes altogether too large and must imbed itself in the vaginal 
walls. I have seen a sufficient number of these cases to satisfy my- 
self that they occur in the practice of the most competent gyne- 
cologists, sometimes, perhaps, from neglect in giving specific direc- 
tions to the patient to report from time to time, so that the behavior 
of the pessary may be watched, but more often from the fact that 
the patient having been relieved of all her symptoms, either forgets 
the pessary, or else feels secure and safe, so long as there is no suf- 
fering which she can not, in her own opinion, attribute to the meno- 
pause, the time when there is the greatest danger of the accident in 
question. 

Pessary entirely imbedded in the Vaginal Walls, except about 
three quarters of an inch. — This patient came to me when she was 
forty-six years old ; she was still menstruating, but irregularly, and 
on one or more occasions had menorrhagia. She was suffering from 
a prolapsus of the uterus which caused her much trouble when she 
was on her feet. I restored the uterus, and used an instrument to 
keep it in place. This gave her relief at once, and she was able to 
take up her duties as in times past. She came to see me several 
times and I made some applications to the uterus which caused a 
slight endometritis. I directed her to continue her visits from time 
to time, in order that I might see how the pessaiy was acting : this 
she did not do, for feeling perfectly Avell, she concluded that there 
was no need of further treatment, and she acted accordingly. Ten 
years passed, and though she began to have a purulent dischiu-o-e 



342 DISEASES OF WOMEN. 

and occasional bleeding from the vagina, still she neglected her- 
self. After a time she called a physician, who made a superficial 
examination, and told her that he suspected that she might have can- 
cer ; he advised her to place herself again under mj care ; this she 
did, and I found the vagina almost completely closed. On the 
right side anteriorly, I found a small portion of the pessary exposed, 
but the rest was imbedded in the vaginal walls and covered over 
by considerable tissue. 

The granular and highly-vascular character of the tissues sug- 
gested that the doctor's suspicion of cancer might be correct. The 
pessary could be felt through the wall of the rectum which appeared 
to be quite thin at that point. 

Passing a sound into the bladder, a part of the pessary appeared 
to be encroaching upon it. With difficulty the finger could be passed 
between the free portion of the pessary and the vaginal wall until 
it reached the cervix uteri, which was normal. The pessary had to 
be removed, yet the task appeared to be a difficult one. There was 
so much haemorrhage caused by the examination that I dared not 
divide the tissues which enclosed the pessary, neither did I feel that 
I could with safety rapidly and forcibly tear the instrument out of 
its place, fearing that I might do damage to the rectum and blad- 
der. I finally adopted the following method with success : Using a 
Sims' s speculum, I seized the part that was exposed in the anterior 
part of the vagina with a very strong forceps, and with a small 
finger-saw cut out the section within reach. I then laid hold of an 
end and by traction caused the pessary to revolve until another por- 
tion came into the place of the one removed ; this was sawed off, 
and piece after piece was taken out in this way until the whole was 
removed. 

The sinns was washed out for the purpose of cleaning it and 
stopping haemorrhage, but there was so much bleeding that I had to 
use a tampon to control it. 

The patient did quite well, and beyond a marked thickening of 
the vaginal walls, has now no trace of the injury. 

Since my experience with this case, I have seen quite a number 
of cases of imbedded pessaries, and have removed them in the way 
described. Two cases I have in mind now in which the pessaries 
were imbedded in the posterior vaginal wall, were treated by sawing 
out the anterior half or third of the pessary, and then by turning 
the remaining portion around it was destroyed and removed without 
breaking down or dividing the tissues surrounding it. 



CHAPTER XX. 

HYPERTROPHY OF THE CERVIX TJTERI. 

This is a peculiar and rather rare affection. It differs from the 
enlargement of the entire uterus, which occurs in pregnancy and in 
some of the inflammatory affections. The hypertrophy is confined 
to the vaginal portion of the cervix, and is distinct from the enlarge- 
ment of the supra-vaginal portion, which occurs in connection with 
metritis, subinvolution, and pregnancy. 

Pathology. — The only change in structure of the cervix is in 
quantity. The length of the cervix is increased, which is the main 
point in the pathology. Sometimes it is thickened, but not in pro- 
portion to the elongation. It is characterized by great increase in 
length without increase in the diameter of the cervix, and no 
changes occur in the composition of the tissues. This is a true 
hypertrophy, which occurs from causes wholly different from the 
ordinary conditions which produce hypertrophy. The extent of 
hypertrophy differs in different cases ; this is due, to some extent, 
to the stage of progress when the first examination is made. In 
some cases the cervix projects from the vulva one or more inches, 
while in others the cervix rests just behind the hymen or in the 
vulva (Fig. 165). 

The cervix is generally conical and the os externum is generally 
small, as it should be in the virgin cervix. 

It occurs in the unmarried most frequently, but occasionally in 
those who are married but sterile. 

Syraptomatology. — The symptoms are exactly the same as those 
due to prolapsus. In the first stage there is pelvic tenesmus, and a 
sense of overdistention of the vagina. The presence of this large 
cervix causes irritation of the vagina and consequent leucorrhcea. 
Owing to the great increase in the length of the uterus, it becomes 
doubled up in the pelvis, and this often affects the menstrual func- 
tion, giving rise to dysmenorrhcea. In the last stage of the aff'ee- 



344: 



DISEASES OF WOMEN". 



tion, in which the cervix protrudes from the vulva, there is much 
discomfort ; and the feehng of distention causes great irritabihtj of 




Fig. 165. — Ih-pertrophy of the cervix. (-|.) 



the general nervous system. Excoriations and ulcerations of the 
mucous membrane are produced. 

Physical Signs. — The bimanual touch reveals the fact that 
while the fundus uteri is at its normal elevation, the cervix is either 
down at the vulva or protruding beyond it. At the same time the 
firmness of the vaginal walls, occupying their normal position, shows 
the great length of the extra-vaginal part of the cervix. This sign 
is diagnostic when the cervix is still within the vulva, but when the 
cervix has escaped through the vulva there is prolapsus of the vagina 
which obscures the signs to some extent. Emmet claims that elon- 
gation from prolapsus of the uterus has been mistaken for hyper- 
trophic elongation. This does not seem possible for one who knows 
anything about the rudiments of gynecology. By restoring the pro- 
lapsed uterus, any little elongation which may have come from 
stretching will disappear, while no change of position will make any 
difference of length in hypertrophy. The nse of the sound also 



HYPERTROPHY OF THE CERVIX UTERI. 



345 




helps greatly in determining the extent of the hypertrophic elon- 
gation. 

Causation. — The fact that this affection is limited to the virgin 
cervix makes it appear as if the hypertrophy might be due to neg- 
lected functions, but the fact is that its cause is not known. 

Prognosis. — The hypertrophy yields to surgical treatment very 
promptly. All the 
cases that I have 
treated, five altogeth- 
er, have been com- 
pletely relieved by 
amputation of the 
cervix. 

Treatment. — The 
removal of the super- 
abundant intra-vagi- 
nal portion of the 
cervix by amputa- 
tion, is the only meth- 
od of treatment which 
gives satisfaction. 

Several methods 
of operating have 

been employed, such as the circular method, made with the knife or 
scissors, the ecraseur^ and the galvano-cautery wire. Originally, in 

all of these methods the stump 
was left to heal by granula- 
tion. J. Marion Sims greatly 
improved the operation by 
covering the stump with mu- 
cous membrane. Simon and 
Marckwald made a double- 
flap operation, and I have 
adopted a modification of this 
method. The details of the 
operation, as I perform it, are Fig. 168 
as f ollow^s : 
A rubber cord is passed around the cervix and 
drawn tight enough to control the haemorrhage ; the ends of this 
cord are then seized with a fixation- forceps, which keeps them 
from slipping, and also holds the cervix in the desired position. 

The cervix is divided fi'om the canal outw^ard on either side as 
23* 



Fig. 166. — The first step; splitting the cervix. 





Fig. 167.— The double flaps 
of the amputation. 



. — Dia- 
g'ram of the 
pieces removed. 



346 



DISEASES OF WOMEK 



high up as the amputation is to be made (Fig. 166). The double 
flaps are then made with the scalpel in such a way that the two 

short flaps are on the in- 
side (Figs. 167 and 168). 
The portions removed are 
wedge-shaped. 

Two middle sutures 
are then introduced from 
the cervical mucous mem- 
brane, or short flaps, to 
the outer mucous mem- 
brane, and the lateral sut- 
ures are used in the same 
way as in restoring a bilat- 
eral laceration. Fig. 169 
shows the sutures as intro- 
duced, and Fig. 170 shows 
them when tied. 

Before tying the sut- 
ures the rubber cord 
should be loosened, and if 
there are any vessels that 
bleed freely they should 
be controlled. Slight ooz- 
ing is controlled complete- 
ly by tying the sutures. 
There are two things which have been brought out by experi- 
ence, and these should be kept in mind. The first is, that the cer- 
vix after amputation retracts or shrinks, 
so that it should not be amputated too 
high up, but left a quarter or three 
eighths of an inch longer than it should 
apparently be. It will be found short 
enough two or three months after the op- 
eration. The next point is, that the 
middle and outer layers retract after the 
operation far more than the mucous 
membrane of the cervix ; especially is 
this the case when there is a cervical 
endometritis present. In several of my 

cases, I found several months after the operation that the mucous 
membrane protruded from the os externum, and had to be clipped 




Fig. 169. — The sutures in place. 




Fig. 170. — ^The sutures tied. 



HYPERTROPHY OF THE CERVIX UTERI. 347 

off. This is a simple thing to do, but by observing the directions 
this item of after-treatment will not be required. 

The after-treatment is the same as that employed in the op- 
eration for restoring a lacerated cervix uteri, and need not be de- 
scribed here. 

In a certain nmnber of cases I have noticed that the outer walls 
of the cervix retract more than the mucous membrane after this 
operation. Immediately after the parts have healed, the cervix is 
quite perfect, but in a few months the mucous membrane protrudes 
beyond the muscular wall. This is more likely to occur, I think, 
in case there is a cervical endometritis accompanying the hyper- 
trophic elongation. When this condition of protrusion or prolapsus 
of the cervical mucous membrane is found subsequent to amputa- 
tion, the easiest and quickest way is to draw the superabundant tis- 
sue and clip it oif . 

Just here I may mention that hypertrophic elongation of the 
anterior half of the cervix occasionally occurs in bilateral laceration. 
When this elongation is very great, I have found it best to amputate 
the redundant part as a preliminary to the operation for the lacera- 
tion. This is done in the same way as taking off a finger by the 
flap operation. 



CHAPTEE XXI. 

FIBROMA OF THE UTEKUS. 

These new growths of the uterus belong to the middle period of 
life, occurring during functional activity of the uterus, and are the 
most benign, both in composition and behavior, of all the neoplasms 
of the uterus. They partake far more of the nature of a hyper- 
plasia than a degeneration. Fibromata originate in the middle coat 
of the uterus and in histological composition are the same as the 
tissues which produce them. Efforts have been made to iind some 
difference between the structure of these growths and that of the 
wall of the uterus, and several names have been employed which 
would convey some idea of their structure. Fibroid, fibrous myoma, 
fibro-myoma, and hysteroma are the names that have been used to 
designate these tumors. I prefer the term fibroma, believing that it 
is as comprehensive and indicative of the character of the growth as 
any. By comparing a section of the uterine wall with a section of 
fibroma, it will at once appear that they are very much alike. Both 
are composed of muscular fibro-cells, fibro-plastic elements, and cellu- 
lar tissue. There is also a similitude in their function or, more prop- 
erly speaking, both the tissues of tlie middle coat of the uterus and 
those composing a fibroma are similar in their behavior in this re- 
spect ; they are both given to great increase by growth and decrease 
by atrophy. 

While it is a fact that the same histological elements are found 
in the wall of the uterus and in fibromata, the construction and ar- 
rangement of these tissues differ sufficiently to cause a difference in 
the physical characters of the two. Compared with the wall of the 
uterus the fibroma is more pearly white in color, less vascular, usual- 
ly more dense to the touch, and cuts more like cartilage. 

Fibromata grow usually in the body and fundus of the uterus, 
but in rare cases they have been found in the cervix. All of these 
growths must of necessity begin in the muscular tissue of the wall of 



FIBROMA OF THE UTERUS. 



349 




Fig 171. Fia. 172. 

Figs. 171, 172. — Interstitial fibro- 
mata (Winckel). 



the uterus, but the direction in which they grow varies in different 
cases, and this has led to a very clear and useful classification of 
fibromata. When the tumor remains im- 
bedded in the middle coat of the wall of 
the uterus it is called interstitial (Figs. 
171 and 172), when it grows toward the 
outside, subperitoneal, and when it grows 
toward the cavity of the uterus, submu- 
cous. Figs. 171 to 173 will show the 
three forms classed according to location. 
The subperitoneal variety might well be 
divided into two classes, those that are 
situated outside of the broad ligament 
and those that are within its folds. 

Though very little has been said in books about the fibromata 
which grow within the folds of the broad ligament, the history of 
such differs so much from the ordinary subperitoneal variety that a 
special notice is quite necessary. Fibromata situated in this position, 
instead of becoming pedunculated, extend out- 
ward between the folds of the broad ligament 
and drop down deep into the pelvis. It is not 
until they become quite large that they extend 
up out of the pelvis. Being surrounded by the 
folds of the broad ligament they are more firm- 
ly fixed in the pelvis than other subperitoneal 
tumors, and consequently cause more displace- 
ment of the pelvic organs. The uterus and the 
Fig. 173.— Subperitoneal bladder are usually pushed far over to the oppo- 

and submucous fibro- ., ., j. .-, ^ . , ,, 

mata (Winckel). ^^^^ ^^^6 01 the pelvis, and the pressure upon 

the ovaries and pelvic nerves made by such a 
tumor causes much pain. Fibromata in this position cause the most 
suffering of any of this class of tumors, and they are more likely to 
cause cellulitis than when located elsewhere. In some cases the tu- 
mor drops down very low in the pelvis behind all the pelvic organs. 
One case of an unusually large fibroma which came under my care 
had a large mass behind the rectum which extended down to the 
peritonaeum. It appeared to be a part of the tumor, but I presumed 
that it must be something else. Dr. Thomas Keith saw the case, 
and pointed out that the tumor had split up the broad ligament in 
its growth, and extending downward beneath the peritouieum neces- 
sarily got behind the rectum. 

The location of the tumor has a marked influence upon its his- 




350 



DISEASES OF WOMEN". 



toiy and treatment ; tlie classification should be clearly understood 
and kept in mind on this account. Those that grow toward the in- 
side of the uterus 
may remain broad- 
ly attached to the 
uterine wall or they 
may become pe- 
dunculated. Fig. 
174 shows this lat- 
ter condition. 

They may be 
single, conglomer- 
ate, or multiple. 
The single tumor 
consists of one 
mass, the multiple 
of several masses 
situated apart and 
at different places 
in the uterus, and 
the conglomerate 
consists of a num- 
ber of masses 
growing close to- 
gether and sur- 
rounded by one 
capsule. 

These growths 
occur, as a rule, in 
the body and fun- 
dus of the uterus, 
rarely in the cervix. They vary greatly in shape. When very 
small they are usually round, but as they grow they sometimes be- 
come irregular, especially is this true of the conglomerate variety. 

In all cases the tumor is in a sense distinct from the wall of the 
uterus. The tumor is in the uterine wall, but not a part of it. 
There is in almost all cases a clear line of demarkation between the 
tumor and the tissues of the wall of the uterus. The tissues which 
surround the tumor and separate it from the neighboring tissues are 
chiefly cellular, and are called the capsule. This, after all, is only a 
separation in the arrangement of the tissues of the uterine wall and 
tumor which shows the difference between the two. Were it not 




Fir. 1*74. — Pedunculated submucous fibroid (Simpson). 



FIBROMA OF THE UTERUS. 351 

for this the morbid growth would be very much like circumscribed 
hypertrophy of the uterus. As it is, the development, growth, and 
decay of fibroids are influenced by the uterus, from which they take 
their origin and nutrition, and are governed by the same laws. 

Fibroids occur only during the active functional life of the 
uterus. They increase in size during pregnancy, and generally 
diminish in size after confinement, and after the menopause they 
often disappear with the final atrophy of the uterus. Even in the 
absence of pregnancy the growth of a fibroma resembles the normal 
growth of a pregnant uterus, in the respect that there is simply an 
increase of tissue without change of structure. The rule is that 
fibroids are never seen before puberty, and they usually disappear 
after the menopause, but not always immediately after the cessation 
of the menstrual function. Usually, the menopause is postponed in 
cases of fibroma, the patient continuing to menstruate until fifty 
years and over. Neither does the decrease in the the tumor begin 
as soon as the menses stop in all cases. On the contrary, the organic 
forces which maintained the menstrual function being no longer 
called for are devoted to the growth of the fibroma, and this growth 
may go on for some time after the menopause, but the rule is that 
in time the process of atrophy begins and the tumor diminishes, and 
finally disappears, or nearly so. 

During the growth of these tumors they frequently change their 
position and relations to the uterus. The submucous tumor extends 
more and more into the cavity of the uterus. This change in posi- 
tion diminishes the area of connection between the tumor and uterus. 
It becomes pedunculated, and in this condition is sometimes de- 
scribed as a fibrous polypus of the uterus. This process of expjulsion 
of the tumor from the uterus may go on until separation is com- 
plete, the tumor being expelled as is an ovum in miscarriage. Fig. 
ITJ: shows this. The same changes occur in the reverse direction in 
subperitoneal fibromata. They frequently become pedunculated, 
and it has happened that they have become detached from the 
uterus altogether. When this has occurred (which has not been 
often) there are usually found adhesions of the tumor to the ab- 
dominal viscera, and a vascular communication between the tumor 
and the parts to which it has become attached has been established. 
Sometimes such adhesions occur in tumors which are not peduncu- 
lated, but it is a notable fact that fibromata are the least liable to 
form adhesions of all the neoplasms. 

There are certain facts in the clinical history of fibromata regard- 
ing their growth and decay, which should be noticed. It has al- 



352 DISEASES OF WOMEX. 

readj been stated that we should expect that these fibromata, being 
like the uterus in structure and depending upon it for nutrition, 
would have many features in common with the uterus, and such is 
the case. The growth and decay of fibroids are subject to the same 
laws and influences as the uterus. 

The density of fibromata differs in different cases, and it also 
changes in the same case. They sometimes, especially if large, be- 
come soft and oedematous. Sometimes collections of serum, blood, 
or pus are found in the tumor. These give a feeling of softness and 
ill-defined fluctuation. When this condition is found the tumor is 
usually called a fibro-cyst, but there is a difference in pathology be- 
tween a fibro-cyst and a fibroma with cyst-like cavities containing 
blood, pus, and serum. 

I have seen two cases of fibroma which gave the physical signs 
of fibro-cysts. They were both large submucous fibroids, and both 
were situated in the body of the uterus leaving the fundus free. 
The tumor closed the lower part of the cervix uteri, and the men- 
stnial fluid and secretions of the mucous membrane accumulated in 
the fundus and upper part of the cavity of the body, and formed 
what appeared to be in every way a fibro-cyst. 

After the menopause these fibromata usually diminish or remain 
stationary and give no trouble, except by mechanical action upon 
neighboring organs. The mle is that they either disappear or at 
least give no further trouble. At one time it was believed that 
fibromata were capable of being converted into cancer. That is a 
mistake, I believe. Malignant disease may appear in connection 
with fibromata, but I have not yet found any reliable evidence that 
the one is converted into the other. 

Perhaps fatty transformation is the usual change which takes 
place ; occasionally, calcareous or osseous degeneration occurs. 
Tumors which have undergone calcareous degeneration I have seen 
several times, but I have not seen anything like true osseous forma- 
tions. Perhaps it would express the facts better in most cases to 
call this material bone-like rather than to convey the idea that it is 
true bone. These changes or degenerations in fibromata usually are 
conservative. First the tumor stops growing, and then undergoes 
atrophy, or is transformed into osseous-like or calcareous material, 
but in either case the rule is that the patient is relieved. I believe 
that in some rare cases the tissues soften and suppurate, and septi- 
cgemia is produced. One such case occurred in my practice and 
proved fatal. 



FIBEOMA OF THE UTERUS. 353 

CHANGES IN THE UTERUS FROM THE EFFECTS OF FI- 
BROMATA. 

The pathological changes which take place in the uterus dur- 
ing the presence of a hbroma are of much interest. It becomes 
enlarged in all cases, but most of all in the submucous and inter- 
stitial varieties, less so in the subperitoneal, and least in the 
pedunculated subperitoneal. Certain changes in the mucous mem- 
brane of the uterus usually occur. There are, in many cases, poly- 
poid growths developed, and endometritis is almost always present. 

In regard to the changes in the mucous membrane, which occur 
in connection with fibroma. Dr. Wyder, of Berlin, makes the follow- 
ing statement : 

" Fibro-myomas are said to be likely to give rise to malignant 
diseases of the mucous membrane. Martin has formerly maintained 
that these conditions furnish an indication for total extirpation. The 
reader, ha\ang examined a number of cases, does not share this view. 

" With subperitoneal myomas, the mucous membrane was found 
much thickened ; the most important alteration was a very perfect 
glandular endometritis. In one case, adenomatous polypi were pres- 
ent ; in another, on one side glandular, on the opposite side inter- 
stitial endometritis. 

" For interstitial myomas, three groups must be formed : 

" 1. Where the tumors are separated from the uterine cavity by 
a wall one half to one centimetre thick. 

'' 2. Where the tumor is beneath the mucous membrane bat does 
not project. 

" 3. Where the tumor projects largely into the uterine cavity. 

" Of seven cases in the first group, in one no alterations were 
found; in two, glandular endometritis (mucosa four to ten milli- 
metres thick) ; in three, interstitial endometritis. In most cases the 
vessels were very numerous, and their walls very thick. 

" In the second group, the deeper layers of the mucous mem- 
brane were com|)letely transformed into connective-tissue trabeculoe ; 
at the surface was a greatly dilated capillary network with thick- 
walled vessels. 

" In the third group, interstitial endometritis was found. 

" The thicker the wall separating the tumor from the uterine 
cavity the more is the glandular structure developed (glandular en- 
dometritis) ; the closer the tumor approaches the mucous membrane 
the more pronounced becomes the connective-tissue character of the 
proliferation in the nnicosa (interstitial endometritis). We then 
24 



354 DISEASES OF WOMEN. 

find the mucosa on one side atrophied into connective tissue, and on 
the other in a state of glandular proliferation. As regards the 
source of the hgemorrhages, it should be remarked that no vascular 
changes are to be expected in subperitoneal tumors. It was found 
that, where glandular endometritis was alone present, no haemor- 
rhages had gone before. In the case of interstitial tumors associated 
with glandular endometritis exclusively, there was likewise no pre- 
ceding hsemorrhage. It was present only with interstitial en- 
dometritis. Therefore, haemorrhage will not take place where the 
interglandular tissue is quite intact ; but it will occur where both 
structures proliferate equally (endometritis fungosa), or where one 
or the other form develops predominantly, or where glandular en- 
dometritis exists on one side and interstitial endometritis on the 
other. Compression of the numerous vessels causes venous con- 
gestion ; haemorrhage will set in, especially when glands and tissue 
have proliferated equally. The glands exert no influence on the 
under surface ; their character is usually benign. The border-line 
between mucosa and muscle is intact. Endometritis glandularis is 
of a benign nature." 

These pathological changes in the mucous membrane and the 
increase in its extent by the great enlargement of the uterus, cause a 
marked increase in the vascularity. To this state is due the menor- 
rhagia and haemorrhage which are so generally present in cases of 
fibromata. Deformity of the uterus is produced in many cases, but 
in some even large tumors the uterus presents the form of that of 
pregnancy. It is simply enlarged but not changed in form. There 
is often displacement of the uterus, especially in the interstitial and 
subperitoneal varieties. The tumor either drags the uterus toward 
the side upon which it is located, if it is small, or pushes the uterus 
in the other direction, if the growth is large. 

The cervix uteri may be disturbed in many ways. It is some- 
times greatly elongated and far out of its normal position. Many 
times it is spread out on the tumor so that it appears to be a part of 
it. The canal of the cervix is often tortuous and its caliber lessened. 
The effects of fibroma of the uterus upon surrounding organs are 
due to pressure which may cause derangement of function. These 
effects depend upon the size and location of the tumor, with refer- 
ence to the degree of the derangement. When the tumor is still 
small enough to remain in the pelvic cavity and make pressure to a 
limited extent only, the symptoms produced resemble those caused 
by uterine displacements and small ovarian cysts. The rectum may 
be pressed upon and its function perverted. The bladder may suf- 



FIBROMA OF THE UTERUS. 855 

fer from pressure wliicli may prevent it from distending, or it may 
be rendered irritable and tender from pressure. In some cases the 
pressure may become so great tliat the function of the bladder and 
rectum may suffer, and even the ureters themselves may be affected 
in the same way. I have seen several cases, three, in all, I think, 
where the ureters were obstructed from the pressure of fibromata, 
and the kidneys were affected in consequence. The pressure may 
become so great that the function of the rectum or bladder becomes 
arrested, and inflammation of the cellular tissue or peritonseum may 
occur and prove fatal, I have repeatedly seen slight attacks of pel- 
vic inflammation caused by pressure of fibromata ; one case proved 
fatal from pelvic inflammation and rectal obstruction. I saw the 
patient first when she began to have inflammation, and I found the 
tumor impacted in the pelvis and it could not be dislodged by any 
means. The inflammation progressed, and the obstruction of the 
rectum became complete by the addition to the tumor of the prod- 
ucts of the inflammation. In most cases the tumor can be raised 
Tip out of the pelvis when it becomes large enough to give much 
trouble by pressure. The pressure may be directed upon the pelvic 
nerves so as to cause very great pain. When fibromata escape from 
the pelvic to the abdominal cavity, they do not cause so much 
trouble unless they become very large. They may cause peritonitis 
and intestinal obstruction, but that is rare. They were supposed to 
cause ascites, because fiuid in the peritoneal cavity was found in a 
certain proportion of cases, Keith believes that this fluid is a trans- 
udation from the tumor rather than from the peritonaeum, as in or- 
dinary ascites. The quantity of the flnid is seldom sufiacient to cause 
much trouble. 

Symptomatology, — The symptoms of uterine fibromata are natu- 
rally of three kinds : First, those manifested by the general system, 
which are also called constitutional or remote ; second, those which 
originate in the uterus itself ; and, third, those that are produced by 
the pressure of the tumor upon neighboring organs. The severity of 
the remote symptoms depends upon the size and location of the tu- 
mor. There are a great many patients who do not suffer in general 
health from fibromata of the uterus until the growth has advanced 
to a considerable size. Sooner or later, according to the extent of 
disturbance which the growth causes, the general health becomes 
impaired. The patient becomes ansemic and is generally debilitated, 
because of either the loss of blood or deranged nutrition, or botlu 
These symptoms are not by any means diagnostic, but may come 
from a variety of affections. In the most marked cases, when the 



356 DISEASES OF WOMEN. 

patient is extremely anaemic, the skin becomes slightly bronzed, and 
gives to the patient the appearance of having malignant disease. 
The symptoms which are manifested by the uterus are pain and 
haemorrhage. The pain is not always pronounced, in some cases it 
is not at all persistent. It is irregular, spasmodic in character, and 
is most marked when the tumor is submucous, and least so in the 
interstitial variety. The haemorrhage is the most prominent symp- 
tom of all. It usually comes on periodically, and is, therefore, in 
some cases a monorrhagia. Menstruation is too free, and lasts too 
long, and recurs too often. Bleeding may come at any time, there 
being no regularity whatever in some cases. This symptom is so 
constantly present, that Dr. J. Mathews Duncan called tibroma the 
bleeding disease of the uterus. 

This name is well deserved, for certainly no other affection gives 
rise to so much haemorrhage of the uterus as does this. The size 
of the tumor does not influence the severity of the bleeding. In 
some small tumors the bleeding is greater than in others of mon- 
strous size. It is the location of the tumor which determines the 
haemorrhagic symptoms. It is greatest in the submucous, less in the 
interstitial, and least in the subperitoneal as a general rule. The 
submucous pedunculated variety is the worst of all for causing 
bleeding. A very small tumor of this kind may cause the most 
persistent and exhausting haemorrhage. The symptoms caused by 
the effect of the tumor upon neighboring organs are generally most 
marked when the tumor occupies the pelvic cavity. Then the press- 
ure upon the bladder and rectum causes irritation and functional ob- 
struction of these organs ; less or more pelvic tenesmus of a general 
character is sometimes very severe. The effect upon the bladder is 
to render urination very frequent and sometimes difficult or impossi- 
ble. I have seen three cases in which there was retention of urine. 
The tumor was pear-shaped in all of them, and large enough to ex- 
tend above the brim of the pelvis. The urethra and bladder were 
carried upward, so that the urethra was caught between the tumor 
and pelvis, and compressed. Urination in these cases was, for a 
time difficult, and then retention came. All voluntary efforts to 
evacuate the bladder only made matters worse, by forcing the tumor 
downward and wedging it into the superior strait. Eelief was given 
first by the catheter, and then by pushing the tumor upward, the pa- 
tient being placed in the knee-chest position. Pressure upon the pel- 
vic nerves and ovaries often causes much pain. Pain in the back and 
limbs, which is often present, no doubt comes from the same cause. 

Pressure upon the ureters may cause obstruction and hydro- 



FIBROMA OF THE UTERUS. 357 

neplirosis, and all the unfortunate results to the kidney which must 
follow. In such cases there is at first pain in the region of the 
ureters, and subsequently the symptoms of renal disease appear. 
Fibromata large enough to occupy the cavity of the abdomen give 
very little trouble, as a rule. So far as affecting the neighboring 
organs, very large tumors interfere with free respiration, and the 
action of the stomach and bowels to some extent. The ascites which 
sometimes accompanies fibromata of the uterus was supposed to be 
due to irritation of the peritonseum. It is more likely that it is a 
transudation from the tumor itself, as already stated. This is sug- 
gested by the fact that hydro-peritongeum is usually found in connec- 
tion with oedematous tumors. 

Physical Signs. — The positive signs of fibroma are the increase 
in size, change in form, and consistence of the uterus, and the dis- 
placement or distention of the canal, as related to the body of the 
uterus. The touch discovers the fact that the uterus is enlarged, 
apparently, and by the bimanual touch it usually can be proved to 
be really so. The shape of the uterus is changed in nearly all cases. 
It is irregular in outline, one side being much larger than the other. 
In the subperitoneal variety, this deformity is quite marked. The 
tumor projects from the surface of the uterus so boldly that it can 
be instantly detected. In some of the cases of submucous fibroma, 
and occasionally in the interstitial, the uterus is uniform in shape, 
and appears like a uterus enlarged by gestation, and even when 
there is some irregularity of form it is not unlike that which is often 
found in pregnancy, but the uterus is very hard in the one case, 
while in the other it is very soft. The hard character of the tumor 
and uterus is a very reliable sign of fibroma. In all conditions which 
cause enlargement, the uterus is softened except in fibroma and in 
very rare cases of cancer. Whenever the uterus is enlarged and in- 
durated, fibroma may be strongly suspected. 

Deflection of the canal of the uterus from the center is a very 
important sign of fibroma. The relations of the canal of the uterus 
to the axis of the pelvis, as shown by the sound, are changed in all 
forms of displacement, but the canal is still in the center of the 
uterus. In fibroma the canal is excentric and very often tortuous. 
The use of the sound, by which this displacement of the uterine 
canal can be detected, gives this most valuable evidence of the ex- 
istence of a fibroma. Figs. 175 and 170 will show this point very 
plainly. The one shows a uterus large, owing to subinvolution, 
the other about the same size from enlargement due to a fibroid. 

In not a few cases the canal is so deflected, displaced, or com- 



358 



DISEASES OF WOMEN. 





Fig. 175. Fig. 176. 

Figs. 175, 176. — Enlargement due to subinvo- 
lution compared with that from growth of 
a fibroma (after Winckel). 



pressed, tliat the sound can not be passed. A flexible bougie may 
be used, under these circumstances, and although it will not posi- 
tively show the position of the 
canal it gives valuable indica- 
tions of it. When the sound 
can not be used at all, this valu- 
able sign is not obtainable, but 
the fact that the canal in a large 
uterus will not admit the sound 
is evidence of fibroma. There 
is no other condition of enlarge- 
ment of the uterus in which the 
sound can not be passed, as a 
rule. 

Small fibromata, which oc- 
cupy the pelvic cavity, present 
some physical signs which resemble displacements of the uterus, 
ovarian tumors, tubal pregnancy, the products of former inflamma- 
tions and diseases of the Fallopian tubes. 

The differentiation between flexions and versions of the uterus 
and fibromata is based upon the following facts: In flexion and 
version the uterus is not much enlarged, and, as a rule, can be re- 
stored to the proper position when all signs suggestive of fibroma 
disappear, and then, too, the sound shows that the cavity of the 
uterus is not displaced nor enlarged. Ovarian tumors are distin- 
guished from fibromata by being less dense and not usually fixed to 
the uterus ; one can be moved without the other. Early pregnancy 
is usually distinguished from a fibroma by the history and symp- 
toms, but the physical signs differ. The uterus is soft in pregnancy, 
while it is unduly hard in fibroma. Tiie enlargement and softening 
extend to the cervix in pregnancy, but not in fibroma. Should a 
doubt exist, the differential diagnosis can easily be made in a short 
time by watching the progress of the case. The signs of pregnancy 
will soon become sufficiently pronounced to settle the question. 

The most difficult cases to deal with are those in which preg- 
nancy takes place while there is a fibroma present ; I have seen sev- 
eral cases of this kind. Two of these were pregnant when first seen, 
and in both the diagnosis of fibroma was made and in only one did 
I suspect pregnancy at my first examination. In the others I was 
aware of there being a fibroma present, but I did not detect the 
pregnancy until several months had elapsed. 

Fibromata situated within the folds of the broad Kgament are not 



FIBROMA OF THE UTERUS. 359 

easily distinguished from the products of a pelvic cellulitis, extra- 
uterine pregnancy, and diseases of the Fallopian tubes. The history 
of the case, taken in connection with the physical signs, will usually 
suffice to enable one to make the diagnosis. 

Large fibromata which occupy the abdominal cavity have to be 
differentiated from hbro-cysts of the uterus and ovarian tumors. In 
regard to the distinctive signs by which the diagnosis between 
ovarian tumors and fibromata is made the reader is referred to the 
section relating to the diagnosis of ovarian tumors. 

The solid hard fibroma is easily distinguished from a fibro-cyst of 
the uterus by its density, as recognized by the touch, but a soft 
fibroid may be so elastic as to give the signs of an imperfect fluctua- 
tion, and simulate a cyst with a thick wall. In such cases of doubt 
the chances are in favor of the tumor being a soft fibroma, but if it 
is very necessary to make a diagnosis it may be done by aspiration. 
The accumulation of fluid in the upper part of the cavity of the 
uterus, occurring as a complication of a uterine fibroma, gives the 
physical signs of a tibro-cyst so perfectly that one must certainly be 
led to make a false diagnosis. I have seen two such cases, one was 
a very large intra-uterine fibroma which closed the canal of the 
uterus below by pressure in the latter stages of its growth. The 
secretions of the mucous membrane accumulated at the fundus and 
gave distinct fluctuation. One of the most distinguished gyne- 
cologists of this age saw the patient with me and thought as I did 
that it was a fibro-cyst, but it was not. 

The histories of these cases, especially one which is given further 
on, will show more fully the peculiar character of the pathology and 
the difficulties of diagnosis. 

Causation. — Very little, if anything, is known about the true 
pathogenesis of uterine fibroma ; certain facts in regard to age, race, 
and social relations have been ascertained which favor the occiu'- 
rence of these neoplasms. The age when women are most liable to 
these growths is between thirty and thirty-five years. There. are 
many exceptions to this, however, but it is rare to have these growths 
come before puberty or after the menopause. It may be more cor- 
rect to say that they never occur before puberty and rarely after the 
menopause. In regard to race, the negro is more liable to fibromata 
than the white, although no good reason has been discovered why 
this is the case. The influence of the social relations is stated by 
Thomas Addis Emmet as follows : 

'' The development of these growths is retarded by child-bearing, 
and even by marriage, for the sterile woman is less liable than the 



360 DISEASES OF WOMEN. 

old maid, but in turn she is more so than the woman who has borne 
children." These facts are deductions from large tabulated observa- 
tions of cases bj Dr. Emmet, and are therefore reliable. He also 
gives his views regarding these social states as related to the causa- 
tion of these neoplasms, in the following : 

"Between the ages of thirty and forty years the unmarried 
woman is fully twice as subject to fibrous tumors as the sterile or 
the fruitful. I have already referred to this subject, when treating 
of the causes of disease, and pointed out that this is one of the 
tributes which an unmarried woman pays for her celibacy. It seems 
as if it were the purpose of Nature that the uterus should undergo 
the changes dependent upon pregnancy and lactation about once in 
three years throughout the child-bearing period, and that if the 
uterus is not physiologically occupied in child-bearing there is greater 
liability to the development of fibrous tumors as the woman advances 
in hfe. This will also be the case with the married woman who has 
taken means to prevent conception, as well as with her who has been 
sterile from some cause beyond her control, but to a less degree in 
the latter case. I think I have had occasion to note that the sterile 
woman who has earnestly wished for children does not have her 
liability to fibrous tumor increased by the fact of her sterility, an 
instance, probably, of the remarkable effect of mind upon the body. 
Finally, the woman who may have been fruitful in early life, but 
remained sterile long afterward, from some accidental cause, may 
have a tumor developed, but is less liable thereto from having once 
borne a child." 

Prognosis. — Fibromata of the uterus, while the most frequently 
seen of all the neoplasms of the sexual organs, are the most harmless 
so far as their tendency to destroy life. They occasionally prove 
fatal, but many cases progress until the menopause, when the 
growths disappear altogether or become reduced during the final 
involution of the uterus, so that they are harmless. 

The dangers are, first, haemorrhage, which recurs so often in 
many cases that it endangers life. Very few patients bleed to death 
directly, but some become so reduced by the long-continued loss of 
blood, which impairs nutrition, that death comes as the result of some 
secondary affection which would not have occurred except for the 
exhausted state of the patient. Peritonitis and cellulitis are liable 
to be set up by fibromata, and of the fatal cases peritonitis is a not 
infrequent cause. Softening of the tumor and decomposition may 
cause a fatal septicaemia. Blood-poisoning sometimes occurs during 
the expulsion of extra-uterine fibroma. The tumor being in part 



FIBROMA OF THE UTERUS. 361 

cut off from the circulation undergoes necrosis before its expulsion 
is completed, and causes septicssmia, and death takes place when 
relief and recovery appear to be within the immediate reach of the 
sufferer. Pressure upon the pelvic organs may cause death by arrest- 
ing the functions of these organs. This is most likely to take place 
when the tumor grows in the broad ligament and is therefore fixed 
in the pelvis. I have also seen death occur from pressure upon the 
ureters causing obstruction to the flow of urine, renal disease, and 
finally uraemia. Although there are dangers from all of the com- 
phcations named above, a very small percentage proves fatal even 
when left without treatment ; and by judicious management a large 
number can be relieved entirely or helped suthciently to be able 
to pass through life in comparative comfort. Within the past few 
years such means as ovariotomy, hysterectomy, and electrolysis 
have been employed in the treatment of uterine fibroma, with re- 
sults which raise the hope that the great majority of these neo- 
plasms will be controlled, and the death-rate from this cause re- 
duced to a minimum. 

Treatment. — The size and location of uterine fibromata, and the 
conditions and complications produced by them differ very greatly, 
and hence the treatment must vary with each case. The ways and 
means may be said to vary from the simplest medication to the most 
daring surgery, and each method, if judiciously adapted to the re- 
quirements of cases as they come, gives satisfactory results. 

Medicinal agents have been employed in great variety, but ergot 
alone has been found of real value. The action of ergot upon 
fibromata may accomplish beneficial effects in two ways. By excit- 
ing uterine contractions it may produce expulsion of the tumor if 
its relations to the uterine wall are such that it can be expelled. 
On this account ergot does its best work in the submucous variety 
of uterine fibromata. In the same way the ergot, by causing con- 
traction of the uterine walls, may lessen the area of attachment of a 
subperitoneal fibroma, and arrest or retard its growth by lessening 
its blood-supply. This view of the beneficial effects of ergot upon 
the progress of subperitoneal fibromata, is based upon the fact that 
when such tumors are pedunculated, they do not, as a rule, grow so 
fast as when they are attached to the uterus by a broad base. In 
this respect, the action of ergot is simply to aid in the natural 
method of disposing of these growths, viz., by expulsion, which in 
the submucous or intra-uterine variety is often complete, the grovrtli 
being wholly expelled from the uterus. 

Ergot also acts in another way to arrest the growth of such tu- 



362 DISEASES OF WOMEN. 

mors. By keeping the uterus in a condition of permanent contrac- 
tion, and by contracting the blood-vessels, the size of the tumor is 
diminished, and atrophy takes place. In order to obtain the good 
effects of ergot in this waj, it must be given in liberal doses, suffi- 
cient at least to produce all the contractions of the uterus that the 
patient can endure the pains of, and it must be continued for a long 
time. It sometimes happens that the patient can not take ergot for 
any length of time without having indigestion and loss of appetite ; 
occasionally, also, the uterus fails to contract in response to full doses 
of this drug. In either case it is useless, and should not be con- 
tinued. 

In some cases the use of ergot, while it does not diminish the 
size of the tumor nor aid in its expulsion, appears to retard its 
growth, and it also controls the bleeding which is a great gain. 
When the patient can be guarded against the great loss of blood, she 
may be enabled to live in comparative comfort and usefulness until 
the menopause. 

The monorrhagia can sometimes be helped by treating the endo- 
metrium. 

The endometritis is often attended with fungous growths which 
greatly increase the tendency to hoemorrhage. The removal of such 
fungosities with the curette will often give relief, and the subse- 
quent application of tincture of iodine to the uterine mucous mem- 
brane at regular intervals, is of service. In order to use the cu- 
rette and apply the iodine, it is necessary that the cervical canal 
should be sufficiently large to permit an entrance to the uterine 
cavity. In some cases the cervical canal is so narrow and the cavity 
of the uterus so deflected that such treatment is impossible. 

When expulsion, with or without the use of ergot, has advanced 
far enough to pedunculate an intra-uterine tumor and dilate the cer- 
vix uteri, the tumor can be separated from the uterine wall and re- 
moved by dividing the pedicle. When the dilatation of the cervix 
is complete, and the tumor is expelled from the uterus and is lodged 
in the vagina (the pedicle still remaining attached to the uterus) the 
separation and removal of the tumor are quite easy. 

There are several methods of dividing the pedicle. I prefer to 
use the wire ecraseur. The galvano-cautery eeraseur has been used 
but it is difficult to apply, and it is impossible to avoid burning the 
uterus and vagina, and has no advantages over the wire or chain. 

The ecraseur which I use is modified to suit the wire. The por- 
tion to which the wire is attached is so arranged, that each end of 
the wire is held fast by a pinching screw, so that the loop of wire 



FIBROMA OF THE UTERUS. 



363 



can be lengthened or shortened in a moment (Fig. 177). I employ 

the steel wire nsed for piano or zither strings, the thickness of the 

vdre being adapted to the size of the pedicle. The wire has one 

YQYY great advantage over the cbain in being 

easily applied. It is elastic, and yet stiff enough 

to be easily made to slip over the tumor to be 

snared. 

Objections to the wire or chain ecraseur 
have been raised. There is danger, it has been 
claimed, of the uterine wall being drawn into 
the grasp of the chain and a part of it removed, 
and an opening made directly into the perito- 
neal cavity. The fact is, that as the wire is 
tightened around the pedicle, the tissues are 
forced out of its grasp equally on both sides. 
There is no drawing of the tissues into the 
grasp of the wire. 

If there is inversion of the uterus at the 
point of the attachment of the pedicle, the 
wall of the uterus might be included in the 
eeraseur-wire and removed. This happened 
once in my own practice, and I believe the 
same thing has been done by other operators. 
Fig. 178 shows the condition referred to as it 
occurred in my own patient. 

The inversion of the part of the uterus was 
not detected before the operation was com- 
pleted, but an examination of the tumor 
showed that the inverted portion of the uter- 
ine wall was completely removed. 'No harm 
came from it. The patient did w^ell, but the 
greatest anxiety was felt for some time. 

Sometimes it happens that the tumor, while it protrudes into the 
vagina to a slight extent, is grasped by the cervix so firmly, that the 
wire of the ecraseur can not be applied. The same difficulty has been 
encountered when the tumor — the size of a fetal head — is lodged 
in the vagina. Under such circumstances, the tumor should be re- 
duced by rapidly taking sections of it away with a strong scissoi*s, 
and then the ecraseur can be used, or if the haemorrhage is not 
great the base of the tumor can be enucleated. 

The removal of the base of a tumor is easily accomplished by 
seizing the mass in the center with a tenaculum forceps and separat- 




FiG. 177. — Ecraseur. 



364: 



DISEASES OF WOMEN. 



ing it first from the mucous membrane whicli forms the capsule, 
and finally from the muscular wall. Much care and gentle handling 

of the enucleating instrument should 
be employed, because the muscular 
wall of the uterus at the point of at- 
tachment of the tumor may be ab- 
sorbed, and the base of the tumor 
rest upon the peritonseum. This 
state of affairs I hav^e found in two 
cases which I treated by enucleation, 
the histories of which will be given. 
Intra-uterine fibromata have been 
treated by dilatation, or division of 
the cervix uteri and enucleation be- 
fore they became pedunculated. 

At one time this treatment was 
quite in vogue in this country. The 
operation is difiicult and dangerous. 
The dangers are from shock, hsem- 
orrhage, and septicsemia, and so far 
as I can learn the results have been 
in many cases unsatisfactory. Some 
years ago I abandoned this method 
for other methods of treatment which 
I believe to be less dangerous and 
more effective in such conditions. 
Removal of the ovaries for the relief of small fibromata which 
cause exhausting hemorrhage has given very satisfactory results. 
This plan of treatment was suggested by the fact that these neo- 
plasms disappear, as a rule, after the menopause. Reasoning from 
this it was presumed that by removing the ovaries, and thereby in- 
ducing the cessation of the menstrual function prematurely, the 
same effect upon the fibromata would be obtained. Practically, it 
was found to be so, and hence in properly selected cases the re- 
moval of the ovaries is the best treatment. In some cases, although 
the removal of the ovaries appears to be the best means of giving re- 
lief, it is found impractical. When the ovaries can not be reached 
with sufficient ease to make their removal possible, or when they are 
so closely adherent to the uterus, as they sometimes are, that they 
would require to be dissected from their attachments it is unsafe to 
try to remove them. Under such circumstances it is better to per- 
form hysterectomy. 




Fig. 1 78. — Wall of uterus caught in 
6crascur-wire and removed. 



FIBEOMA OF THE UTERUS. 365 

It is well in view of these facts, to be prepared to remove the 
uterus, when ovariotomy is undertaken for the relief of uterine 
fibromata, for should the one operation prove to be impossible the 
other could be resorted to. Beyond the fact that the ovaries are 
sometimes more difficult to get at in these cases, there is nothing in 
the operation which differs from ovariotomy generally, hence noth- 
ing need be said about it in this connection. 

It should be understood that the exact value of this method of 
treatment is still under consideration, and more time and cases are 
needed to settle the question definitely. All who have practiced 
this method of treatment often enough to obtain valuable experience 
report favorably of it. Wildow states, that in seventy-six cases the 
menopause occurred immediately in sixty-one. In four cases, the 
effect upon the haemorrhage was temporary. In sixty- three cases 
the fibromata diminished. In three cases there was a primary 
diminution and a subsequent increment of the tumor. 

More recently Wildow has given the statistics of one hundred 
and forty-nine cases, of which fifteen died. I presume that the 
death-rate has been less than this with some operators. Should it 
prove to be so great as ten per cent it would become a questionable 
procedure, notwithstanding that the results in the successful cases 
should prove to be satisfactory. 

Hysterectomy for the relief of uterine fibromata has now been 
performed a sufficient number of times to enable one to discuss its 
relative merits with some degree of certainty. 

In the first place it is adapted to large, rapidly-growing tumors, 
which do not yield to less heroic treatment, but render the patient 
useless and threaten her life. 

Dr. Thomas Keith, who, up to this time, is by far the most suc- 
cessful operator, in speaking of this subject, says : 

'' I often ask myself the question : Does a mortality of eight per 
cent justify an operation for a disease that, as a rule, has only a 
limited active life, that torments simply, and that only for a time, 
though of itself it rarely kills ? The mortality of an ordinary uter- 
ine fibroid, if left alone, is nothing approaching a death-rate of eight 
per cent. I doubt even if the mortality of the extreme cases exceed 
this. And, after all, the great difficulty is, not in doing even the 
worst of these operations, but in knowing what are the cases in 
which it is right to advise those who trust tliemselves to us, to run 
the risk of a dangerous operation, with all its attendant miseries. 
Could we get the mortality down to five per cent in the bad cases, 
and these only are the fit subjects, then one might advise interfer- 



366 



DISEASES OF WOMEN". 



ence with a more easy mind. I do not think that we can so advise, 
if the mortality can not be kept under ten per cent." 

It appears at the present time that hj the judicious use of other 
means of treatment the number of cases which will require hyster- 
ectomy in the future will be diminished, but still there may always 
be some that will demand it. Dr. Keith says that all his operations 
were done on account of repeated haemorrhages and ruined health. 
He also states that the time chosen for the operation was a day 
or two before menstruation was expected, because the patients had 
then regained more or less force from the loss of the previous 
period. 

Electrolysh. — This method takes the highest rank among the 
means of treating fibroma of the uterus. In order to fully compre- 
hend this subject, some knowledge of the elements of electro-physics 
should be obtained. The following treatment of this matter was 
prepared for me by my friend Prof. Charles Jewett : 

Some knowledge of electro-physics is 
essential to the inteUigent use of electric- 
ity as a therapeutic agent. The limits of 
this chapter, however, will not permit 
more than a brief mention of such ele- 
mentary facts as are necessary to a proper 
understanding of the terminology and 
technique of electrical treatment in gyn- 
ecology and a few words of advice with 
reference to the selection of apparatus. 
For a more extended knowledge of the 
subject the reader must be referred to the 
many standard works on electrical science. 
The physical forces are no longer re- 
garded as having a distinct and inde- 
pendent existence and manifesting them- 
selves by their effects upon matter, but 
rather as affections or conditions of mat- 
ter itself. In short, the different physi- 
cal forces are different modes of motion 
in the molecules of bodies. The phenom- 
ena of electricity, then, are due to a mode 
of molecular motion. It is an important practical fact that the 
molecular forces are mutually convertible. Any one may be trans- 
fonned into any other force. Familiar examples of the conversion 
of force are the transformation of heat into light when a bit of wire 




Fig, 179. — Electrical action in a 
sinde cell. 



riBEOMA OF THE UTERUS. 367 

is brought to incandescence in a gas-flame, the generation of heat by 
friction or impact, the production of light by electricity, and so on. 
In practice, electricity is derived from a variety of sources. The 
electricity of a frictional machine is the product of the mass motion 
of the glass plate, or rather of the muscular force expended in turn- 
ing the plate. Magneto-electricity is obtained from magnetism. 
The electrical energy of a galvanic battery is the result of the chem- 
ical action of its elements. In accordance with the law of the cor- 
relation of forces, the amount of electrical energy, by w^hatever 
method developed, is the mathematical equivalent of the force ex- 
pended in producing it. 

Galvanism, faradism, and static electricity are the kinds of elec- 
tricity commonly used for therapeutic purposes. Galvanism, for use 
in medicine, is generally obtained from chemical sources. A simple 
example of a galvanic cell may be constructed by immersing, at a 
short distance apart, a plate of gas carbon and one of zinc in dilute 
hydrochloric acid in a common glass tumbler (Fig. 179). A moment- 
ary chemical action takes place in the cell. The chlorine of the acid 
enters into combination with the zinc, forming the chloride of zinc, 
which goes into solution in the fluid of the cell. Bubbles of free 
hydrogen collect upon the surface of the carbon plate. It can now 
be shown, by methods familiar to electricians, that the free ends of 
both plates are charged with electricity. If the free ends of the 
plates be conjoined by means of a copper wire the plates imme- 
diately deKver their charges through the wire. But since the chemi- 
cal action now becomes continuous the charge is continuously re- 
newed, and thus a constant flow of electrical disturbance is main- 
tained. If the wire be disconnected, the chemical action ceases in 
the cell, and the flow of electricity is arrested. Both are renewed 
on again connecting the plates. The active metal, zinc, is called 
the "positive element of the cell, the carbon the negative element. 
The conjunctive wire, the plates, and the intervening colnmn of 
fluid constitute the electrical circuit. The continuous propagation 
of the molecular disturbance in the circuit gives rise to the term 
current. For convenience, the current through the wire is said to 
flow from the carbon to the zinc plate, though in fact we have two 
cmTents, one of positive electricity flowing from carbon to zinc, and 
one of negative electricity from zinc to carbon. The free end of 
the carbon, from which electricity flows through the wire, is termed 
the positive pole, the corresponding end of the zinc is the negative 
pole of the cell. If the conjunctive wire be cut, the free ends of the 
wire now become the poles of the circuit, one the positive, the other 



368 DISEASES OF WOMEK 

the negative pole. For ordinary therapeutic uses metallic plates 
variously covered with moist sponge, chamois, or otherwise-, are at- 
tached to the free ends of the wire, and are commonly termed 
electrodes (from eXeKTpov and 0809, the electrical pathway). The 
positive electrode, sometimes called the anode {ava and 0S09, the way 
up), the negative electrode, the cathode {Kara and 0S09, the way 
down). A combination of several galvanic cells in a common cir- 
cuit is a galvanic lattery. 

Bodies which, like the conjunctive wire, are capable of transmit- 
ting electricity, are called conductors. Others which lack this prop- 
erty are termed non-conductors. These terms, however, are merely 
relative. Different substances differ widely in their conducting power, 
and, strictly speaking, no body is so good a conductor as to oppose 
no resistance to the passage of the current, none so poor a conductor 
that its resistance may not be overcome in some measure by power- 
ful currents. The metals are examples of good conductors, silver 
and copper being the best. Glass, vulcanite, ivory or bone, and dry 
wood are good non-conductors. Such substances, when used for the 
purpose of preventing leakage of the current, as in the handles of 
electrical instruments, are termed insulators. 

The capacity of a galvanic cell for generating electricity is de- 
nominated its electro-motive force. It depends upon the energy of 
the chemical action in the cell, and therefore varies with the ma- 
terials which enter into its construction. In a battery of similar 
cells arranged in series (the zinc of one cell being connected with 
the carbon of its neighbor), the electro-motive force wiU be increased 
in proportion to the number of cells. 

The term cm-rent is not only applied to the flow of electricity in 
the circuit but is also used in a quantitative sense. It is employed 
in the sense of current strength, and represents the quantity of elec- 
tricity flowing through the circuit. The term resistance is used to 
denote the degree of obstruction opposed by the circuit to the pas- 
sage of electricity through it. As may be inferred from what has 
already been said with reference to the conducting power of bodies, 
resistance varies with the materials of which the circuit is composed. 
In case of wire, or other conductor of given material, the resistance 
varies directly as its length, and inversely as its sectional area. JSTot 
only the conjunctive wire, but the exciting fluid as well, and the 
plates of the cell offer a greater or less amount of resistance. The 
total resistance within the cell is designated the internal, in distinction 
from that mthout, which is called the external resistance of the circuit. 

The electro-motive force of a battery corresponds approximately 



FIBROMA. OF THE UTERUS. 369 

to tlie horse-power of a steam-engine, the current to the motion of the 
machinery. The value of the current in a given circuit will depend 
not only on the electro-motive force of the battery, but also upon the 
resistance in the circuit. It will vary directly as the electro-motive 
force, and inversely as the resistance. In other words, the current will 
be equal to the electro-motive force divided by the resistance. This 
is the law of currents, and is kno^vn as Ohm's law, so named from its 
discoverer. Letting C stand for current, E for electro-motive force, 
and R for resistance, the law may be conveniently expressed by the 

following formula, C = ^ . Putting R' for the internal resistance, 

F 

and R^' for the external, we have C = ^, ^ . By application of sim- 
ple algebraic rules, any three of these quantities being known, the 
other may be found. A knowledge of this law and its uses is of the 
utmost importance in all practical applications of electricity. By its 
aid many of the perplexing problems encountered by the beginner 
in electrical practice may be readily solved. 

For quantitative determinations we must have units of quantity. 
The adopted unit of electro motive force is the volt, that of resist- 
ance the ohjn, and that of current the ampere. A volt is the amount 
of electro-motive force necessary to yield one ampere of current 
through one ohm of resistance. An ohm represents approximately 
the resistance offered by 230 feet of pure copper wire of 'No. 16 
American wire gauge. A volt is very nearly the electro-motive 
force of a single Daniell's cell. 

To illustrate the application of Ohm's law in practice, suppose 

the electro-motive force of a given galvanic cell to be 1*5 volts. Let 

the internal resistance be one ohm, and that of the connecting wire 

E 1*5 

•5 ohm. We have C — -f^^r-r^-D// = tt — ^' ^^^ ampere is then 

1 V -|- K lo 

the strength of current that flows in such a circuit. If, now, we 
have a battery of fifty such cells, connected in series, the total elec- 
tro-motive force of the battery will be 75 volts, and the total internal 
resistance will be 50 ohms. Suppose that a portion of the human 
body and the necessary instruments for regulating, measuring, and 
applying the current be introduced into the external portion of the 
circuit. If the tissues of the body in the circuit offer a resistance 
of 1,000 ohms and the instruments and conducting wire a total of 
450 ohms, the entire external resistance will be 1,^50 ohms. From 

75 
Ohm's formula we have - — . , ,^ = '050. The current in this 
25 5U+ 1,450 ^ 



370 DISEASES OF WOMEN. 

case will therefore be fifty thousandths of an ampere, or, as it is ex- 
pressed, 50 miiliamperes, the milliampere being one thousandth of an 
ampere. 

From C = ^,^-^, we get R^+ K^' = ? and R" = ^ - R'. 

The required data being given, we may by means of this formula 
find the total external resistance or any component part of it. Sup- 
pose a portion of the body be connected in circuit with the same 
battery, instruments and conducting wires as in the case last cited. 
Suppose the current is now found to be 50 miiliamperes. The 
resistance, exclusive of that offered by the tissues interposed, being 
known, we may readily compute the resistance of the portion of the 
body through which the current is passed. We have from the last 

formula, E^' = ^ - R\ W = -^ - 60 = 1,450. Deducting the 
O *u50 

known resistance of the wire and instruments, we have 1,450 — 450 

= 1,000. The resistance offered, then, by the portion of the body 

placed between the electrodes is 1,000 ohms. 

E E 

From the formula C = ^, . ^,^ we also have R' = — — H^' 

xv -j- xt L> 

and E = C {W -{- W). The application of these formulas in practice 

is obvious from the illustrations already given. 

When enormous resistances like those of the human body are con- 
cerned, such elements in the computation as the internal resistance of 
the battery, if it be low, and that of the conducting wires may be disre- 
garded. The results will be sufficiently exact for practical purposes. 

The resistance offered by the human body is by no means a con- 
stant quantity. It varies by hundreds of ohms not only with the 
amount of tissues interposed in the circuit, but also with the varying 
character of the tissues in different parts of the body, the area of the 
electrodes and their firmness of contact, with the degree of moisture 
of the part to which they are applied, and other causes. It is well 
known that the conducting power of the electrodes and the com- 
pleteness of the electrical contact may be increased by moistening 
the electrodes with a saline or acid solution, instead of plain water, 
a fact often useful in practice. 

The accumulation of hydrogen bubbles which takes place upon 
the surface of the carbon plate when the battery is in action weakens 
the current in proportion to the extent of surface so covered. This 
phenomenon is known as polarization. Yarious means are provided 
in the construction of different batteries for overcoming this diffi- 
culty, or, as the expression is, for depolarizing. For example, de- 



FIBROMA OF THE UTERUS. 371 

polarization is accomplislied in certain cautery batteries by occasion- 
ally agitating the fluid and thus removing the hydrogen from the 
plate. In ordinary batteries the effects of polarization are partially 
or wholly obviated by various chemical provisions. 

By electrolysis {eXeKTpov and \vo-t<;) is meant electro-decompo- 
sition, or the resolution of the chemical compound into two con- 
stituent parts by the action of the current. For a simple illustration 
of electrolysis, place in a beaker-glass a solution of iodide of potas- 
sium. Selecting for the electrodes some non-corrodible metal, plat- 
inum-wire for example, immerse them at a short distance apart in 
the solution. Iodine will be liberated at the positive pole and potas- 
sium at the negative. A few drops of starch-water dropped into the 
solution will demonstrate the presence of free iodine at the positive 
electrode, and, since the potassium enters into combination with 
oxygen and hydrogen, forming the hydrate of potassium, an alkali, 
its presence may be shown at the negative pole by a few drops of 
red-litmus solution. The body thus decomposed is termed an electro- 
lyte. Since bodies which are — in an electrical sense — unlike, attract 
one another, and like bodies repel, chemical elements attracted to 
the positive pole are called electro-negative elements, those which go 
to the negative pole electro-positive elements. In general, substances 
liberated at the negative pole are termed anions^ those set free at 
the positive pole, cations. 

Galvanic currents, with which we have thus far dealt, are con- 
tinuous currents. The current of a faradic machine is an interrupted 
current, consisting of a series of more or less rapidly recurring im- 
pulses. Moreover, it is an alternating current — that is to say, each 
alternate impulse traverses the circuit in opposite directions. Since 
the polarity is reversed with each impulse there is no diflerence in 
the therapeutic action of the electrodes. The electricity of a static 
machine is also characterized by instantaneous discharges. Another 
important difference between faradic, or especially static and gal- 
vanic electricity, is one of tension. By tension or potential is un- 
derstood power to overcome resistance in the circuit. Faradic, and 
especially static electricity, are characterized by high tension. The 
value of the electric current, other things being equal, depends 
upon the difference of potential between the point from which and 
that to which the current flows, just as the force of a waterfall de- 
pends upon the difference of water-level above and below the fall. 

Space will not permit a description or even an enumeration of 
the various forms of the galvanic cell, which are more or less suited 
to therapeutic requirements. For portability the latest forms of 



372 



DISEASES OF WOMEN. 



the chloride of silver batterj leave little or nothing to be desired. 
Their principal disadvantage is a high and varying internal resist- 
ance. The J answer well, however, the ordinary requirements of 
galvanization. For a stationary battery for office use the Leclanche 
battery, or more especially some one of its modifications, is deservedly 
becoming popular. Any amount of electro-motive force required 
by the physician for galvanization or electrolysis may be obtained 
by the use of a large number of cells, and for cleanliness, con- 
venience, and durability they are thus far unexcelled. A battery 
of forty to sixty such cells, though somewhat cumbersome, can 
easily be disposed of in a closet or in the cellar. With proper 
use it is always ready for work, and requires little or no attention 

for long periods. The best 
modification of the Leclanche 
battery that has been brought 
to our notice is the Law bat- 
tery (Fig. 180). Its mechan- 
ical construction is of the 
highest order. It is subject 
to absolutely no deterioration 
when not in use — which can 
not be said of most batteries, 
even of the Leclanche pat- 
tern. The carbon plate is 
prepared by a special process, 
and, with proper care, lasts 
indefinitely. The only parts 
that require renewal are the 
zinc and the exciting fluid, 
and these but once in two or 
three years in ordinary office use. This is an important advantage 
over other forms of the Leclanche cell in which the carbons as well 
as the other elements require renewal, from time to time, at an ex- 
pense little short of the first cost of the cell. 

For cautery purposes, it is not unlikely that a small portable bat- 
tery of storage cells will be found most suitable. They can be 
readily recharged during the intervals of use by means of a few 
gravity cells. The well-known cautery batteries of Piffard, Daw- 
son, and Byrne are extensively employed, but are inferior to a good 
storage battery in reliability and in convenience of use. 

There is a common misapprehension in regard to the efl:ect of 
the size of cells upon the current. The electro-motive force of a 



I 




Fig. 180.— Law cell. 



FIBROMA OF THE UTERUS. 373 

cell of given elements remains tlie same whether the size be large or 
small. The internal resistance of the large cell is less than that of 
the small one since the resistance of the column of Huid between 
the plates varies inversely as its sectional area. Through a low ex- 
ternal resistance large cells will give more current than small ones. 
If the external resistance be very great the current will be practically 
the same whatever the size of the cells. This may be shown by 
Ohm's law. With a battery of fifty cells, each having an electro- 
motive force of 1*5 volt and an internal resistance of 1 ohm, let the 

E 75 

external resistance be 10 ohms. We have C =: ^ = 

K -\-ii 50 -f- 10 

= 1'25. A battery cell with plates five times as large will have one 

fifth the internal resistance, or -2 ohm. The current from fifty such 

75 
cells through the same resistance will be = 3*75. Thus 

there is a great gain in the use of large cells when the external re- 
sistance is small, as is the case in cautery batteries. ]^ot so in case the 
current is passed through great resistances like those of the human 
body. Suppose, for example, the external resistance is 1,450 ohms. 

75 
With the battery of fifty small cells we have C = — — . ^ ,^^ 
-^ ^ 50 -j- 1,450 

= -050. With the battery of fifty large cells of the same material C = 

75 

— -OSl-j-. There is practically no gain in the strength 

J.U -J" JL,Tbt)U 

of current. The only advantage of the large cells for the purpose of 
electrolysis or galvanization is the greater amount of materials and 
consequently greater durability. 

In cautery batteries, however, the resistances are comparatively 
small, and here large cells are used. Moreover, only a small num- 
ber of cells is required. If it were possible to construct a circuit 
having no external resistance one cell would give as much current 
as a thousand. With a cell having an electro-motive force of 1*5 

1'5 
volt and an internal resistance of -2 we have C == = 7*5 ; 

'2 — )— 

1 500 
with a thousand such cells we have C = ' = 7*5. It will be 

^00 — [- 

readily seen that where very low external resistances are concerned 
very little gain in current will be effected by multiplying the num- 
ber of cells. As the external resistance increases a larger number of 
cells will be required, hence the large number of cells needed when 
the enormous resistances of the human body are to be overcome. 
Exact dosage is no less important in electricity than in the use of 



374 



DISEASES OF WOMEN. 




Fig. 181. — Milliamp^remeter. 



other remedial agents. The old method 
of measuring the current by the number 
of cells employed was entirely wanting 
in precision. Owing to the gradual ex- 
haustion of the battery-fluid by use, the 
varying resistance of the conducting- 
cords, the electrodes, and the dilferent 
portions of the body, there can be no 
constant relation between the number of 
cells in circuit and the current strength. 
A convenient and reliable galvanometer 
is, therefore, to the electro-therapeutist 
what the apothecary's balance or graduate 
is to the dispenser of drugs. The vertical galvanometer will be 
found the best for the purpose, and 
it should cover a range of from 
one to live hundred milliamperes. 
The milliamperemeter of Barrett 
and Perret has proved a satisfacto- 
ry galvanometer in our nse (Fig. 
181). 

For the purpose of regulating 
the current strength a current se- 
lector or switch-board, by means of 
which a large or small number of 
cells can be switched into circuit, 
has been commonly employed. This 
device is open to the objection that 
it uses different portions of the bat- 
tery unequally ; that it does not 
permit a sufficiently gradual in- 
crease or decrease of the current ; 
and that, as the switch jumps from 
one stud to the next, at the instant 
when it touches both, one cell is 
short-circuited and its force thus 
wasted. Instead of the switch-board 
I have used, for some time, a 
rheostat or current - regulator, in- 
vented by Mr. H. S. Bailey, elec- 
trician of the Law Telephone Com- 
pany, of ^ew York (Fig. 182). Fig. 1 82.— Rheostat. 




FIBROMA OF THE UTERUS. 375 

This instrument consists of a bundle of carbon plates insulated from 
one another, placed in v^ertical position, and attached to a vertical me- 
tallic rod, by means of which it can be racked up and down in a col- 
umn of water. When connected in circuit, the strength of current 
is regulated by the depth of immersion as in the common water- 
rheostat, but with the advantage over that instrument of much greater 
precision and greater facility of manipulation. By means of this 
rheostat a resistance of from twenty to two million ohms can be 
thrown into circuit. The current can thus be gauged at will from 
an imperceptible strength of one or two milliamperes to the full 
force of the battery. The current may be increased, diminished, or 
turned off altogether, without the slightest shock to the patient, an 
important advantage over the switch-board. This method of regu- 
lating the current has the advantage, too, of using the entire battery 
at once, whether the current applied be one or a thousand milliam- 
peres. Since each cell does the same amount of work as its neighbor 
all parts of the battery constantly maintain an equable strength. 
Moreover, the comparatively trilling cost of the regulator is a by no 
means unimportant item. The introduction of the Bailey regulator 
and the milliamperemeter marks an important advance in electro- 
therapy. 

The Method of applying the Electric Currejit in the Treatment of 
Fibroid Tumors. — The method of using the current which I have 
adopted, is to pass an electrode into the cavity of the uterus, and in- 
sulate that portion of the instrument which rests in the vagina. The 
other electrode — a broad one — is applied over the abdominal surface 
where the tumor is located. The electrode in the uterus is connected 
with the negative pole of the battery, and the other with the positive. 
The current then is gradually turned on, until it is as strong as the 
patient can tolerate it, and is continued for eight or ten minutes. 
This is repeated every third or fourth day. The electrode which is 
introduced into the uterus is shaped like a uterine sound. The por- 
tion of it which occupies the cavity of the uterus is made of plati- 
num. The rest is copper covered with hard rubber, and over this 
there is a sheath of rubber, which can be moved forward or back- 
ward to regulate the length of the portion to be insulated, which 
varies, according to the depth of the canal of the uterus in different 
cases. 

Figo 183 shows this instrument. The electrode which Apostoli 
uses for the outside of the tumor is composed of sculptor's clay, 
rolled, cut to a size sufficient to cover the prominent part of the 
tumor, and about half or three quarters of an inch thick. The clay 



376 DISEASES OF WOMEN. 

is covered with some thin fabric like cheese-cloth, to keep it to- 
gether. This is applied over the abdomen, and then a broad me- 




FiG. 183. — Uterine electrode. 



tallic plate applied over the clay. This answers very well so far as 
fitting the rounded abdominal surface, and by its own weight it 
keeps its place with and also protects the skin from irritation. It is 
not very convenient, however. The clay has to be kept wet all the 
time, in order to be ready for use when required. It also requires 
to be made warm in cold weather, and is not very clean to handle. 
Owing to these inconveniences of the clay, other materials have 
been used. I employ a sheet of absorbent cotton about half an inch 
thick when wet, and gently compressed, and over that an electrode 
made of a number of small metallic plates fastened together with 
wire. In this way the electrode fits the irregular curves of the ab- 
dominal walls. Even this is not exactly what I desire. While it is 
free from the objections of the clay it does not adapt itself to the 
body as well as the clay. This leads me to believe that something 
more convenient than anything now in use may be yet devised. 

This gives the method of using electrolysis in the way which 
appears to me to be most acceptable, but there are modifications as 
practiced by some which should be noticed. 

Some prefer to anaesthetize the patient and use a current stronger 
than the patient could otherwise bear. This may insure more rapid 
progress in the treatment, but it is perhaps more dangerous and 
disagreeable to the patient. I prefer a current which the patient 
can tolerate, and continue it longer at a time and repeat the treat- 
ment more times. 

Sometimes it happens that the cervix uteri is displaced, so that 
the electrode can not be introduced into the uterine cavity. In such 
cases, a needle-pointed electrode should be thrust into the tumor, and 
the current passed in the usual way. Apostoli speaks of this as 
making an artificial canal in place of the normal one of the uterus. 

In order to maintain this canal made by the first puncture, the 
current used must be strong enough to destroy the tissues in imme- 
diate contact with the instrument. Should the opening close another 
puncture can be made at the next treatment. 

In cases where there is severe menorrhagia Apostoli recommends 
the introduction of the positive electrode into the uterus, and using 
a current strong enough to slightly char or dry the mucous mem- 



FlBPwOMA OF THE UTERUS. 37Y 

brane, and in that way arrest the bleeding. This is no doubt good 
practice when the bleeding can not be arrested by other means such 
as curetting or the application of astringents. 

(illustrative cases.) 

Fibroma of the Uterus ; Recovery without Treatment. — This case 
illustrates a class, not by any means large, in w^iich the disease 
runs its course without causing much discomfort or impairing the 
health to any great extent, and without being influenced by treat- 
ment. The patient was higlily nervous and very active, had a good 
constitution, and enjoyed good health. When she was about thirty 
years old her menstrual flow became more free than formerly. She 
had up to that time been quite regular and normal in regard to men- 
struation. This slight menorrhagia continued, and occasionally was 
quite profuse. She also had backache and pelvic tenesmus, which 
rendered her less active and enduring than in her earlier life. I 
first saw her professionally when she was thirty-one years of age. 
She was then single and enjoying fair health. I supposed that she 
might have a fibroma of the uterus from the history, and suggested 
that I should find out by examination the exact condition. This she 
objected to. 

From this onward she continued about the same. The menor- 
rhagia continued, and she had at times dysmenorrhoea and leucor- 
rhoea, but all of these did not impair her health or usefulness suf- 
ficiently to make her willing to submit to treatment. At forty 
years of age she married, and then her symptoms increased consid- 
erably, but in the intermenstrual periods she was fairly well. Four 
years after her marriage she had an attack of malarial fever of a mild 
order, and then the menorrhagia and dysmenorrhoea became worse, 
and I then had an opportunity to examine her, and found that there 
was a fibroma in the posterior wall of the uterus, probably inter- 
stitial. She soon recovered from the malaria and its effects, and 
then her uterine troubles became as they had been formerly. About 
this time I made an application of iodine to the cavity of the uterus, 
but as she improved she did not return for further treatment. I 
saw her occasionally while visiting other members of her family, and 
heard that she was about the same as formerly. 

According to her own statement, she was not at any time quite 
well, but not ill enough to be willing to be treated. When she was 
forty-nine she again consulted me, and I then found that the men- 
strual flow had been diminished for over one year, and had been ab- 
sent altogether for three months. She was quite nei'vous and rest- 



378 DISEASES OF WOMEN". 

less, just as many are at tlie menopause. I examined tlie uterus, 
and found that the fibroma had almost disappeared. The uterus 
was much larger, at least twice as large as it should be after the 
menopause, but not one third the size that it was when I first ex- 
amined the case. I have seen her since, and find that she is quite 
well. 

Interstitial Fibroma of Large Size, complicated with Endometritis ; 
treated by Tincture of Iodine to the Endometrium, Ergot during the 
Menstrual Period, and Mild Continuous Current of Electricity. — A 
strong and vigorous lady who had always enjoyed good health until 
after she was twenty-five years old, was first seen when she was 
thirty-one. She was married at twenty-six, and soon thereafter 
began to menstruate too freely ; she never was pregnant. When 
first seen she was prostrated with a severe menorrhagia. I then ob- 
tained the facts given above, and also learned that she had suffered 
from pelvic pain, leucorrhoea, backache, and a gradually increasing 
menstrual fiow until the time I saw her, when she was quite ex- 
hausted. The uterus and tumor extended upward to haK-way be- 
tween the pubes and umbilicus. Stimulants and ergot were given, 
but the flow continued, and then the tampon was used, which stopped 
it. She improved from this time, quite perceptibly, but was pulled 
down at the next period, though not to so low a point as before. She 
was then put under treatment for the endometritis. The hot-water 
douche was tried, and the whole endometrium touched with tincture 
of iodine. In order to do this it was necessary to dilate the os exter- 
num, and then by using the pipette, the application could be made 
very thoroughly. There was at first considerable catarrh of the cer- 
vix, and for that a few applications of tincture of iodine and carbolic 
acid, equal parts, were made. Under this treatment the menstrual 
flow became less free, althougli the tumor increased slightly in size. 
After remaining under treatment intermittently for about two years, 
she was induced to place herself under the care of a physician who 
made the acquaintance of her husband. This gentleman treated her 
twice a week with a mild continuous current of electricity, which he 
passed through the tumor by placing one electrode upon the ab- 
domen and the other upon the back. 

Three quarters of a year were occupied in this way, but without 
any improvement ; she neither gained nor lost, except that her flow 
was more free. She returned to my care again, and I resumed the 
treatment of the endometritis with iodine ; I also continued the elec- 
tricity, but did so by procuring a battery for the patient, and having 
one of my assistants teach her how to use it. In place of applying 



FIBROMA OF THE UTERUS. 379 

it twice a week, as the doctor had done, she used it every day, and I 
am satisfied that she used it as effectually as the doctor. 

This treatment was kept up for two years. Whenever her menses 
became very free, or if the leucorrhoea returned, she came for treat- 
ment, otherwise she used the electricity alone. The tumor had 
diminished perceptibly, but her general improvement was out of 
proportion to local changes, excepting that the endometritis was re- 
lieved. After this she went to live in the country, and was not seen 
again until she was forty-six years old. I then found that the 
menses were normal, and that the tumor was very much reduced. 
When first seen, I conld with ease introduce the sound into the 
uterus seven and a half inches, while at the age of forty-six the 
cavity of the uterus measured less than four inches. 

Interstitial Fibroma of the Uterus treated with Ergot ; Recovery, 
— This patient was thirty-four years old, married, and had one child 
when she was twenty-three years old. After its birth she suffered 
from leucorrhoea and backache, but did not have any treatment until 
she was twenty-seven years of age. She then began to menstruate 
too freely, and was treated by her physician, but without effect. 
The menorrhagia, while it depressed her, did not disable her alto- 
gether, so she w^ent about her duties until she noticed a tumor in the 
abdomen ; she then came to me for advice. I found the uterus en- 
larged, extending upward to within two inches of the umbilicus. 
The cavity of the uterus was deflected to the right and backward, 
and the sound passed to the depth of seven inches. The fibroma 
occupied the left anterior wall and projected considerably to the 
left, giving to the whole mass (uterus and tumor) an irregular out- 
line. 

There was some endometritis, and the patient was slightly anae- 
mic, but otherwise her health was good. Half a drachm of fluid 
extract of ergot was given before meals, for about a month, in the 
hope that it might incline the tumor toward the cavity of the 
uterus, and by partially expelling it bring it within reach for the 
operation of enucleation. At the end of a month there was no 
change in the position of the tumor ; ergot was then used hypoder- 
mically about twenty minims every third day. This excited strong 
uterine contractions, which lasted for about an hour or more each 
time. This treatment was continued for three weeks, but without 
changing the position of the tumor, though it diminished in size. 
The hypodermic use of the ergot was then given up, because the 
patient became tired of the pain it caused. She continued to take 
the quantity first given by the mouth for seven or eight weeks, and 



380 DISEASES OF WOMEN". 

the tumor continued to decrease in size. The hypodermic use of the 
ergot was tried again for nearly a month, but was only used every 
fourth day. At the end of three months all treatment was stopped 
because the patient's digestion became impaired. She was kept 
upon tonic treatment for a time until her general condition improved, 
and again the ergot was resumed, using it hypodermically and by 
the mouth alternately. The menorrhagia gradually subsided, and at 
the end of six months the tumor had diminished over two thirds of 
its former size. The cavity of the uterus was only three and three 
quarter inches in depth. No further treatment was deemed neces- 
sary. Three years after the treatment was suspended the patient 
was in good health, and her menses were regular. 

The uterus was above the average size, but not much so. The 
left wall was more than twice the thickness of the other, so that 
there was a trace of the fibroma remaining, but it was harmless. 
While the object for which the ergot was originally given was not 
attained a happier result followed. 

The ergot so influenced the nutrition of the growth as to cause 
dropsy. This is a rare effect of ergot, and yet it sometimes is pro- 
duced in certain cases. 

Submucous Fibroma ; Expulsion by the Natural Efforts ; Separation 
of the Pedicle with the Ecraseur ; Recovery. — The patient was un- 
married and thirty-five years old ; she was large, strong, and had 
always had good health. She began to menstruate at fourteen, and 
continued to do so in a perfectly normal way until she was twenty- 
eight years old. At that time the menstrual flow became more free 
and lasted a little longer. From this time onward, the menstrual 
flow gradually but not regularly increased, until she established a 
well-marked menorrhagia. This undermined her health consider- 
ably. She lost flesh, and became quite anaemic. She had charge of 
a branch of a large business establishment, and was an efiicient and 
trusted employe, but her duties became very trying to her, espe- 
cially at her menstrual periods, at which times she was obliged to 
stay at home occasionally. Still she persisted in her work until she 
was taken ill and confined to her bed. She called in a poorly-quali- 
fied physician who failed to relieve her ; subsequently her employer 
requested me to take her in charge. I found the uterus enlarged 
from the pressure of a fibroma, which was evidently intra-uterine. 
She also had all the signs and symptoms of a pelvic cellulitis in the 
left, broad ligament. This terminated in resolution, and in about 
two weeks she was able to be around again. Although still weak, 
she returned to her duties, but her menorrhagia continued. Every 



FIBROMA OF THE UTERUS. 381 

effort was made by tonics and good food to improve her strength. 
She was requested to rest at her menstrual periods, and to take ergot 
and cannabis Indica in moderate doses at such times. She con- 
tinued to be quite ansemic, but dragged along with her work as 
best she could. I saw her only occasionally, and found that the 
tumor did not grow very fast, and she did not lose much in general 
strength. This went on for six years, when she began to have se- 
vere pains from uterine contractions ; for this I saw her and sug- 
gested that she should give up the use of ergot. I did not see her 
again for about five months, when I was called in haste to her, and 
found her suffering from great expulsive pains. She told me that 
it was time for her to menstruate, but she had had very little flow, 
but instead these extreme pains. Examining the abdomen, I found 
that the size of the uterus was greatly increased, and that in the 
absence of uterine contractions, there was distinct fluctuation at the 
upper third of the uterus. I presumed that the fluctuating mass 
was a cyst which had rapidly developed since the time that I had 
seen her before. On making a vaginal examination, I found the 
cervix dilated about two inches and a solid fibroma protruding at the 
OS externum. Opium was given to ease the pain which was ex- 
hausting her, and at the end of twelve hoars I found that although 
the pains had modified a little, they had continued. The dilatation 
of the cervix had progressed. The opium was continued in large 
doses. It was then night, and I desired her to sleep. The night 
was passed fairly well, she had pains, but slept between them. Next 
day the opium was suspended and the pains returned with renewed 
vigor. Toward evening, after having several violent pains, they 
ceased, but were followed by the most distressing pressure upon 
the rectum and bladder. There was no cessation to this suffering, 
and I was called in haste to see her. I found the tumor the size of 
a fetal head, pressing upon the peringeum and firmly impacted in 
the pelvis. The fluctuating mass was still felt in tlie pelvis but 
lower down. Her sufferings were such from the complete obstruc- 
tion of the rectum and bladder that immediate relief was de- 
manded. 

She was at once conveyed to a private room in the hospital, and 
the removal of the tumor effected. The operation was as follows : 

It was impossible to determine the location or character of the 
attachment of the tumor, nor could I pass the chain of the ecraseur 
over it, so firmly was it fixed in the vagina. To avoid incision of 
the pelvic floor and delivery of the tumor en masse — a very bad 
method which has been practiced — I determined to diminish the 



382 DISEASES OF WOMEN". 

size of the mass bj exsection with the scissors and forceps. It was 
night, so I had to use artificial light reflected from the head-mirror. 
Through Sims's speculum it was easy to cut away enough to enable 
me to determine that the pedicle was not large, and that the chain 
of the ecraseur could be passedo While making this examination, 
and also while adjusting the chain, there was considerable discharge 
of dark blood from above the tumor. The pedicle was easily di- 
vided, and the remains of the tumor were further reduced^ so that 
it could be brought through the vulva without laceratioUo The re- 
moval of the mass was followed by a gush of dark blood, at least 
a pint in all, and there were several clots which remained in the 
vagina. These were rapidly removed, and then I could see the 
distended and empty uterus. The blood had accumulated in the 
uterus above the tumor, and given rise to the fluctuation and rapid 
increase in the size of the uterus which I had observed. 

With the light reflected from the head-mirror I was able to ex- 
amine the entire cavity of the uterus most thoroughly. By holding 
the lips of the os externum apart with an elevator and sponge-holder, 
the view of the interior of the uterus was complete. The site of 
the attachment of the tumor could be clearly seen, and the gradual 
contraction of the uterus was also noted. 

There was nothing of interest in the after-history of the case. 
The patient made a good recovery, and gradually regained her health 
and strength. It is now four years since the operation, and she has 
continued in perfect health. 

Uterine Fibroma, supposed to be a Uterine Fibro-Cyst ; Death from 
Septicaemia during the Process of Expulsion. — An unmarried lady of 
somewhat delicate organization came under my observation when 
she was thirty years of age ; she said that five years previously she 
began to suffer from menorrhagia, and soon afterward began to ob- 
serve a gradual increase in the size of the abdomen. When first 
seen, the tumor was about the size of the uterus at the seventh 
month of gestation ; all the physical signs of a submucous fibroma 
were obtained. Her general health was somewhat impaired, she 
was anaemic, owing to the menorrhagia, which was not excessive ; 
otherwise she was in fairly good health, and, as her circumstances 
in life were good, she was able to be around and enjoy life. She 
was placed upon a general tonic treatment, with the use of ergot and 
cannabis Indica, which were given at the menstrual period. She 
continued for three years to do fairly well, occasionally having an 
attack of menorrhagia, which pulled her down a little, but she readily 
recovered from this, and went about in her usual way. 



FIBROMA OF THE UTERUS. 383 

She was seen only occasionally, and the general plan of treatment 
was not changed. 

About the fourth year after she came under my observation, she 
had an attack of menorrhagia which was rather more severe than 
usual, and she took larger doses of ergot, and continued the remedy 
longer than was her habit. This controlled the menorrhagia but 
produced severe uterine pain, for which I was called to prescribe. 
I then carefully examined the tumor and found that it had increased 
in size considerably from the time 1 had seen her before — about four 
or five months. I found that the upper portion of the tumor was 
quite elastic, and that there was distinct fluctuation extending 
through an area of about five inches. I then suspected a fibro- 
cjst. 

Soon after this she was seen by my distinguished friend. Dr. T. G. 
Thomas, who, without knowing of the patient's history or my own 
opinion, made the diagnosis of fibro-cyst. During the remainder of 
that winter and the next spring she had more menorrhagia, and was 
kept more continually under the influence of ergot ; when summer 
came she had regained some of her former strength, and went to the 
country, where she remained for several months. She returned in 
the autumn slightly improved, but about a month afterward began 
to suffer from severe pains, due to uterine contractions. These pains 
increased in severity and frequency, until she was unable to leave 
her room. She then sent for me, when to my surprise I found the 
cervix uteri fully dilated and the tumor partially expelled from 
the uterus, occupying and completely filling the vagina. The ergot 
was suspended, and she was reheved from her severe pain by the 
use of opium, but the pressure upon the pelvic organs became so 
great that it was necessary to try and relieve her. The lower por- 
tion or capsule of the tumor began to slough, and I then determined 
to remove all of the tumor, or as much of it as possible. In the 
mean time the uterus as examined through the abdominal wall 
had not diminished very much in size, and the fluctuation was more 
marked and more extensive. She was at this time very anaemic, and 
so weak that I dared not anaesthetize her. So I proceeded without 
doing so, with the patient in Sims's position, and with the aid of 
Sims's speculum I rapidly removed all that portion of the tumor 
which occupied the vagina, using the tenaculum forceps and hiemo- 
static scissors. There was very little haemorrhage, and the patient 
derived very great relief from the removal of this portion. She was 
permitted to rest for a few days and ergot was again given, which 
produced expulsion of another mass about as large as the one that 



384 DISEASES OF WOMEX. 

had been expelled, this was removed in the same way as the other; 
while remoying a portion which extended up into the cervix uteri, 
about five or six ounces of Huid escaped from the cavity of the 
uterus. Immediately after this it was found that the fluctuation was 
greatly lessened, and the size of the tumor, as observed through the 
abdominal walls, had markedly diminished. She had after this con- 
siderable fever and disturbance of the stomach, and this, along with 
her marked anaemia, prostrated her so that nothing could be done 
for nearly a week but to sustain her. At the end of that time her 
temperature diminished somewhat, she was able to take nourishment 
and stimulants, and as considerable more of tlie tumor had been ex- 
pelled, a third attempt was made to remove it. I was able to re- 
move all that portion outside of the cervix ; I then endeavored to 
remove a portion that was still within the grasp of the cervix ; as 
soon as I did this, about four ounces of putrid matter were discharged 
from the nterus. Although there was not much haemorrhage, and 
the patient did not complain of pain, she was so much exhausted and 
her pulse was so feeble that I was obliged to desist, feeling confident 
that if I undertook to remove the remainder of the tumor, the 
patient would succumb. The cavity of the uterus was carefully 
washed out with carbolized water, and the patient put to bed and 
stimulated and nourished as well as possible. Two days afterward, 
when she had rallied considerably, I found that the lower por- 
tion of the cervix had contracted around the tumor, and that it was 
breaking down and decomposing. I thoroughly and repeatedly 
washed out the inner cavity of the uterus, and hoped by so doing to 
control the septicaemia from which she was suffering in a most 
marked degree. I also felt confident that if I could bring her 
strength up again that I might be able to remove the whole of the 
tumor. But this proved to be impossible, although the uterus con- 
tracted again, in fact, sufficiently expelled the tumor to partially 
dilate the cervix. She at no time was in any condition to bear so 
formidable an operation as completing the enucleation of the tumor. 
The septicaemia still proceeded, and she died about five years from 
the time that she first came under my observation. 

On post-mortem examination it was found that a portion of the 
fibroma as large as a fetal head remained, and was attached at the 
posterior and right lateral wall of the uterus, and that it closed the 
cavity very thoroughly by pressure, and that there was still a little 
fluid in the fundus uten. It was clearly evident from this, that this 
obstruction of the canal below and the distention of the cavity of 
the uterus above, which gave rise to the fluctuation obtained at her 



FIBROMA OF THE UTERUS. 385 

examination, explained the resemblance of the physical signs to those 
obtained in the uterine fibro- cysts. 

It is a number of years since this case came under my observa- 
tion, and I am satisfied that had I known then as much as I know 
now about the management of sucb cases I should probably bave 
been able to save her. As it is, I still think that had she sent for me 
when she returned from the country, and before her strength became 
so much exhausted from the efforts at expulsion, I might have been 
able to remove the whole of the tumor ; but it was otherwise. 

A Case of Submucous Fibroma in which Pregnancy progressed to 
Full Time, and the Tumor was completely expelled about a Week 
after Confinement. — This case w^as seen in consultation with Dr. 
Bodkin, who, when called to attend her in confinement, found a 
sohd tumor which so completely filled the pelvis that he could not 
reach the os uteri. The labor-pains continued, the membranes 
ruptured, and the cord became prolapsed. The tumor was recognized 
as a fibroma which extended down into the cervix and at the same 
time upward toward the fundus. It was a long, narrow tumor which 
may have assumed that shape by stretching during the growth of 
the pregnant uterus. 

We agreed to try to deliver by version. Accordingly, when the 
patient was anaesthetized the doctor succeeded in pushing up the 
tumor out of the pelvis, and passing his hand past the tumor and 
through the os, which was quite dilatable, he turned and delivered. 

I then took charge of the placenta, which was retained for some 
time. To facilitate its delivery and at the same time to investigate 
the tumor, I passed my hand into the uterus and was able to make 
out by bimanual touch the size and location of the tumor. It was 
oblong, as already stated, and situated in the anterior wall a little to 
the left side, and extended from the cervix nearly to the fundus, 
and evidently was immediately beneath the mucous membrane. 

The patient did very well considering all things ; she had con- 
siderable haemorrhage at the time, and the discharge afterward was 
free and at times offensive, and she had long-continued after-pains. 

About seven or eight days after her confinement she had an at- 
tack of tenesmus, and in the hope of obtaining relief she got up to the 
commode, and by vigorous expulsive efforts expelled the tumor. It 
was much shrunken, no doubt, but even then the doctor estimated 
that it was about seven inches in length and three inches in diam- 
eter. She subsequently did well. 

In this connection it may be stated that uterine fibromata cause 
sterility, as a rule, owing perhaps to the endometritis which is usu- 
26 



386 DISEASES OF WOMEN. 

ally present, and when pregnancy takes place miscarriage generally 
occurs. Still, I have seen at least four cases that went to full time. 
In all except the one recorded above the tumors were subperitoneal 
and not large. 

Extreme Dilatation of the Cervix Uteri and Expulsion of a Sub- 
mucous Fibroma while only Slightly Pedunculated; The Case diag- 
nosticated as Inversion of the Uterus; Operation and Recovery. — 
This patient came to my hospital clinic and gave a history of menor- 
rhagia for years, and for several months past a metrorrhagia and 
uterine pain. She was quite anaemic, but had always been well and 
strong until the excessive menstruation came. She also stated that 
she visited the outdoor department of tiie Woman's Hospital of 'New 
York, and the gentleman who saw her said that her womb was 
turned inside out, that she should enter the hospital for operation, 
and that her case was a dangerous one. 

I presumed that the diagnosis made was inversion of the uterus, 
and on asking the doctor about the case he told me that he believed 
it to be so. On my first examination I found a tumor in the va- 
gina which, in size and shape, was exactly like an inverted uterus. 
The mass was covered with uterine mucous membrane. Absence 
of the fundus and body of the uterus in the upper part of the pel- 
vis was observed by the bimanual touch. That portion of the mass 
which was uppermost was larger than that which is usually found 
in inversion of the uterus, but in the center of it there was a slight 
depression which is generally found in inversion. Passing the 
sound around the tumor gave evidence that the vagina was at- 
tached to the upper part of the tumor, but by pressing the tumor 
to one side and separating the vagina from it, I could see that there 
was uterine mucous membrane above the vagina, which extended 
upward, inward, and over the tumor. By seizing the tumor and 
twisting it round upon its axis, I also observed that the upper pare 
of the vagina did not move with it as would have been the case if 
there had been inversion of the uterns. From these signs I con- 
cluded that the tumor was a iibroma, with a small but very short 
pedicle attached to the fundus uteri, and that the cervix and lower 
portion of the uterus were so completely dilated that the vaginal 
and uterine walls were continuous. 

I presume, that in time, the tumor would have dragged the fun- 
dus uteri downward and produced inversion. This has occurred. 
In fact, it is not an unusual thing to find a partial inversion of the 
uterus caused by fibromata during their expulsion. 

The pedicle was divided with the ecraseur and the tumor re- 



FIBROMA OF THE UTERUS. 387 

moved. The cavity of tlie uterus then appeared like a cup-shaped 
dome at the termination of the vagina. A sponge, in a holder, was 
gently pressed against the fundus uteri, and held there until the 
uterus contracted, which it did quite slowdy. This was done to pre- 
vent a possible inversion from taking place. The patient recov- 
ered very promptly. 

Soft Fibroma ; Atrophy of the Muscular Wall of the Uterus at the 
Point of Attachment of the Tumor ; Enucleation after Dilatation of the 
Cervix Uteri and Partial Expulsion; Recovery. — The patient was 
forty-nine years old, married, and had had two children, the last one 
sixteen years before the time when she came under my care. She 
was a strong, healthy lady, and had been well until she was about 
forty-five years of age. At that time she began to menstruate more 
freely than at any previous time in her life, but being told that it was 
due to "change of life" she did nothing for it, until she became so 
weak that she sought advice of a practitioner who treated her locally 
for ulceration of the cervix which he said she had. She grew worse, 
the bleeding was more free and lasted longer at each period, and 
she had a profuse watery discharge at other times. Then uterine 
pains came on, which she said were like the first pains of labor. 
This was the history which I obtained when called to sse her the 
first time. 

On examination I found the cervix well dilated, and part of a 
soft fibroma occupying and filling the upper part of the vagina. 
The pressure gave her much discomfort, and I found that the por- 
tion in the uterus was quite as large as that which occupied the 
vagina. Without giving the patient an anaesthetic, I removed all 
that was outside of the uterus with the ecraseur. There was no 
pain and very little bleeding caused by the operation. The patient 
being fatigued by remaining in Sims's position I did nothing more 
for two days, and at the end of that time the larger part of the 
mass was expelled from the uterus. It was oblong but not pedun- 
culated. All that was protruding from the os externum was re- 
moved with the ecraseur^ and the stump was seized with a double 
tenaculum forceps and enucleated. Traction being made with the 
forceps the mass w^as separated from the capsule with a blunt cu- 
rette. There was very little pain caused until the mass was sepa- 
rated all round and the deepest attachment was reached. Then the 
patient began to complain. This was fortunate, because it made me 
very careful. I simply made steady traction and counter-pressure 
with the curette. When the mass came away I could see the peri- 
tonaeum very plainly at the bottom of the cavity. My assistant 



388 DISEASES OF WOMEN. 

also observed it, and recognizing what it was, lie naturally was quite 
anxious. A space, about the size of a twentj-five cent piece was ex- 
posed. It had not been wounded at all, but appeared as if it had 
separated from the tumor very easily. To make sure that there was 
no mistake I examined by the touch and found the parts exactly as 
tliey appeared to be on inspection. 

Submucous Fibroma of Large Size extending through the Uterine 
Wall to the Peritonaeum ; treated first by Partial Exsection with the 
Galvano-Cautery and Several Years after by Enucleation ; Recovery. — 
This was a hospital case which I saw with Dr. Gushing. The tumor 
was large, and extended down into the cervix on one side and could 
be easily reached. The patient was suffering greatly from bleed- 
ing. Partial excision was made by passing two large curved needles 
through a section of the tumor, and then passing the wire be- 
low the needles, and cutting it off by heating the wire. Section 
after section was removed in this way, until all that portion which 
could be reached conveniently was removed, about two thirds of the 
whole, perhaps. The operation was long, and I did not think it 
prudent to continue the efforts to remove the whole mass. Recov- 
ery from the operation was without interruption, and the patient 
was much improved. The menorrhagia subsided, she gained her 
former strength, and was able to make her living as a laundress. 

In a few years the tumor had grown again, and all the old 
symptoms returned and were worse than ever. Dr. Gushing had to 
see her for several attacks of menorrhagia, which nearly proved 
fatal. She then came into the hospital. The tumor was nearly as 
large as it was before, and she was extremely feeble and ansemic. 
There was a cardiac mitral murmur. The officers of the hospital 
strongly advised that I should not operate, and I would have gladly 
followed their advice, but the patient begged that I should try 
again to help her, and I agreed to do so. The tumor was low down 
in the pelvis and projected beyond the opposite side of the cervix. 

Ether was given, and the pulse improved a little under its influ- 
ence. The capsule w^as divided with the therm o-cautery, and sepa- 
rated from the tumor over its exposed portion. A strong forceps 
was fixed in the mass, and while strong traction was being made 
the enucleation was performed with the spoon-saw of Thomas. 
When I had nearly completed the separation, I noticed that there 
was very little resistance on the part of the uterine wall at the 
upper part ; I then made a bimanual examination and found that 
I had passed through the muscular coat of the uterus entirely. 
I was fearful that if I made any further effort to complete the 



FIBROMA OF THE UTERUS. 389 

enucleation I might wound the peritonaeum. The detached por- 
tion was separated from the rest, and the operation stopped. The 
portion left was about the size of a hen's egg, . There was not 
much bleeding, but I can only say that the patient was living when 
she was put to bed. The uterus contracted fairly well. There was 
no further haemorrhage, but a free discharge of serum continued for 
a" number of days. I felt sorry that I had not been able to remove 
the whole of the tumor, but was glad that her life had been spared. 
She improved slowly in strength, and was able to leave the hospital 
in three weeks. The heart-murmur, which was presumed to be 
largely due to her extreme anaemia, proved to be due to mitral in- 
sufficiency, and although she had no more trouble from menorrhagia, 
she did not fully regain her strength. She took up her old occu- 
pation, but it was more than her strength could endure. A little 
over two years after the operation she died suddenly of heart-fail- 
ure. The post-mortem revealed the heart lesions which proved 
fatal. The part of the tumor which was left had not grown, in 
fact, it probably had diminished. The scar at the point of the 
deepest enucleation showed that there was no middle coat of the 
uterus at the side of attachment of the tumor. These facts proved 
conclusively that in operating I had gone through to the perito- 
naeum, as I thought I did at the time. 

The following cases, treated by hysterectomy, are from the work 
of Dr. Thomas Keith : 

Large Solid Fibroid, Weight, Forty-two Pounds; Supra-Vaginal 
Hysterectomy; Recovery. (Keith).— Mary C, aged twenty-eight, 
was sent into the Royal Infirmary by Dr. Robertson, of Ardros- 
san. She had sought relief in many quarters in vain. The tumor 
was very large, and was first noticed '^Ye or six years before. She 
was wasted about the chest and arms, like a case of old ovarian 
disease. 

The abdomen measured forty-nine inches at the umbilicus ; the 
tumor was firm and solid throughout. The ensiform cartilage was 
turned upward, and the growth extended under the sternum and 
ribs ; close to the sternum there was a large projection the size of a 
child's head. No trace of the ovaries could be detected. The greater 
part of the pelvis was occupied by the tumor. There was no dis- 
tinct cervix, only a small triangular projection drawn to the left 
side, almost beyond reach of the finger. For several years no great 
inconvenience had resulted ; menstruation was never in excess, and 
for the last fifteen months it had entirely ceased ; since then, the 
increase in the tumor had been rapid, and she could do little or noth- 



390 DISEASES OF WOMEN. 

ing owing to its weight. She sat all day knitting ; at twenty-eight, 
her life-prospects were anything but bright. 

For obvious reasons, this patient was not taken down to the 
large theatre, but was operated on in the ward, on the 18th of April, 
1881. Sulphuric ether was given, and the operation was performed 
under carbolic-acid spray. The sponges, thirty in number, had 
been lying for a long time in a five-per-cent solution of carbolic 
acid ; they were washed in hot w^ater, and then put into a two-per- 
cent solution, and wrung almost dry. These were used over and 
over again, and were not w^ashed in any fresh solution during the 
operation. Dr. Wilson was present from Glasgow, and there were 
about twenty visitors and students. The first incision measured 
twelve inches ; it terminated four inches above the pubes, so as to 
avoid the bladder, which was to be elevated on the tumor. On the 
right side, the broad ligament rose as high as the crest of the ilium. 
The left broad ligament was largely spread over the half of the 
tumor as high up as the ribs. The opening w^as then enlarged to 
twenty-two inches, and, by dint of hard pushing and patience, the 
huge mass was slowly moved forward as far as its connection on the 
left side would permit. 

The right ovary was easily seen. On searching for the left, it 
was found to be transformed into a long, tense, umbilical-like cord, 
seven or eight inches in length. Here and there along this tense 
band were several small cysts. It was so imbedded in the tumor 
that it never could have been removed. The right, broad ligament 
was transfixed by soft-iron wires, secured and di voided ; all bleeding 
from the tumor was prevented by a series of strong-locking forceps. 
The fibroid was now more easily dealt with. It was drawn for- 
ward, so as to put on the stretch its enormous connection on the 
left side. About a dozen powerful-locking forceps, ten inches in 
length, were now applied to the broad ligament before and behind. 
The whole was then cut downward, and the mass enucleated as low 
as possible. A strong, soft-iron ligature embraced the base, which 
was of great thickness. 

The tumor was then cut away, the stump showing a section of 
the cervix in the centei. The forceps were removed one by one, 
and all bleeding vessels separately tied. Some of these were large, 
and one threw blood over the assistant's head. There was much 
trouble in finding some bleeding points among the loose cellular 
tissue of the huge gap now left. 

The hgemorrhage was mostly venous. All present could see that 
the condition was full of danger, and that secondary haemorrhage 



FIBROMA OF THE UTERUS. 391 

into this loose tissue was not one of the smallest risks of the opera- 
tion. When all oozing seemed to have ceased, the stump (the thick- 
ness of the leg) and the end of the right, broad ligament were se- 
cured, with much tension, outside ; a glass drainage-tube was fixed 
in above the stump, and the wound closed bj forty silk sutures. 
The operation lasted one hour and three quarters. After much 
blood and serum had escaped from the tumor, its weight was fortj- 
two pounds. 

Ten hours after the operation, five ounces and a half of sirupy 
blood were removed from the pelvis through the tube. The pulse 
was 94 ; the temperature 102-2° ; rising two hours afterward to 
103*4:°. During the night, back-pain was relieved by injections of 
morphia. 

The first day was passed fairly well. In the evening the pulse 
was 126, and the temperature 102*2° ; flatulence was troublesome. 
She felt weak, and had whisky and water to drink. There were 
only four ounces of bloody serum from the tube. 

On the third morning, the pulse was 120, and the temperature 
104°. 

On the fourth day, the pulse was 114 to 125 ; the temperature 
ranged from 101° to 103*5°. 

On the fifth day, after a restless night, the temperature had risen 
to 106° ; it fell to 104°, and again in the afternoon it rose to 105-5.° 
There was oedema of the labia, and much cellular infiltration in the 
pelvis. She looked very ill during these days, not caring for food, 
though taking stimulants freely ; on the sixth day the pulse dropped 
to 92, and the temperature also fell to 101*6°. The tube was re- 
moved, there being only a tablespoonful of reddish serum in the 
pelvis. On the ninth day the wound was found healed throughout. 
The stump was dry and sweet. The pulse and temperature almost 
normal. 

In the third week there was again a rise of pulse, and of tem- 
perature from 101° to 103.° This continued for ten days, and 
caused some anxiety. 

On the eighteenth day, the wires were loose and were removed. 
The loop was two inches and three quarters in diameter. Seven 
weeks after the operation she left the hospital. She is now a strong 
woman, in perfect health, and can do anything. 

Soft Bleeding Fibroid; Intra-Peritoneal Treatment of Pedicle; 
Recovery. (Keith).— In 1876, Dr. Kidd, of Alyth, sent me an un- 
married woman — a domestic servant — with a fibrous tumor, low in the 
pelvis and extending to the umbilicus. She was no longer able for 



392 DISEASES OF WOMEN. 

her situation, partly from pain and partly from excess at the menstrual 
periods. She was twenty-nine years of age, and of fairly healthy 
appearance. I advised her to delay interference, unless such be- 
came absolutely necessary. After three years she came again, very 
anxious for relief. She was much changed ; the tumor now filled 
the abdomen ; she was extremely angemic, and quite unfit to make 
her hving in any way. The tumor varied much in size : very large 
and tense before menstruation, much smaller and softer after this 
was over. The loss of blood was sometimes very great. 

Operation was on July 16, 1879. Carbolic spray was used. 
An incision not exceeding ten inches was made ; by taking time, 
the tumor molded and could be pushed through the opening. 
Both broad ligaments extended up to the fundus of the tumor on a 
level with the ribs. The portion containing the ovarian vessels was 
first transfixed and ligatured, locking-forceps being put on close to 
the tumor, before the ligament was divided. The same process was 
repeated on the other side. The tumor was then separated down- 
ward all around from its cellular attachments, and a soft-iron wire, 
secured quite low down — in this case, almost round the top of the 
vagina — by Koeberle's instrument. There was thus left a large 
cavity, from which the pelvic portion of the tumor had been shelled 
out. Koeberle's instrument — five and a half inches in length — was 
left dipping into the pelvis, as it could not be secured outside. 
There was little bleeding from the separated surfaces, and the wound 
was kept as open as possible around the instrument, to allow of the 
escape of serum. 

The operation lasted one hour and a quarter. There was a good 
deal of pain, and several opiates were required during the afternoon, 
There was very free perspiration for some days. The highest pulse 
reached was 124, about thirty hours after the operation ; the highest 
temperature was 100*5°. Recovery was uninterrupted. The serre- 
noeud came away with the slough in ten days ; she returned home 
thirty-two days after the operation, the wound being quite cicatrized 
for some days. 

The tumor was a soft, oedematous fibroid, and weighed nineteen 
pounds. This patient has enjoyed perfect health since the operation. 

Fibrous Tumor of Uterus, containing an Inflamed, Suppurating 
Cavity; Operation; Recovery. (Keith). — An unmarried woman, 
aged forty-four, was admitted into the Royal Infirmary in February, 
1874, under Dr. Matthews Duncan. She was a pale, thin, un- 
healthy looking woman. She had granular, everted eyelids, and 
was haK-blind from inflammation of the cornea. Up tiU the pre- 



FIBROMA OF THE UTERUS. 393 

vious June her health was fairly good. She was then obh'ged to 
give Tip her situation as cook in London, where she had lived for 
more than twenty years. 

Menstruation was regular and normal. Five weeks before ad- 
mission a tumor was detected. It was hard, elastic, quite fixed, and 
reached to the umbilicus. The cervix was drawn to the left side of 
the pelvis ; it was almost beyond reach of the finger, and felt as if 
lost in the tumor. This was supposed to be ovarian. I never had 
any doubt that the case was one of uterine fibroid, and declined to 
operate on it. 

After two months' residence in the hospital she was dismissed, 
and went to her friends in the north. 

In the course of the summer she began to write letters to say 
that she suffered severely, and that the tumor had increased. She 
was importunate, and wished something tried. At last, wearied by 
her importunity, she was allowed to come back. The tumor had 
certainly got much larger; its appearance was changed. It was 
very tender now, and had become prominent on the right side, push- 
ing the loin outward. There was some free fluid. The feeling of 
elasticity was less marked, while that of a deep, obscure fluctuation 
was pretty distinct. 

The relations in the pelvis were the same, the tumor filling the 
whole upper pelvis. It was everywhere fixed and immovable. On 
September 5th, a needle was put in at the umbilicus, and sixty 
ounces of a dark-bro^vn fluid were removed. This was pronounced 
to be ovarian. There was little apparent diminution of the tumor. 
Much irritation followed the puncture, and in ten days the tension 
was greater than ever. The aspirator was again used ; the same 
quantity of fluid, which was again said to be ovarian was removed. 
This time much relief followed. She was again sent away, for I 
had not changed my mind, and still thought the tumor was uterine. 
She was encouraged to hope that, as menstruation seemed about to 
cease, the tumor would quiet down. 

In a few weeks she was back again, urgent for operation at any 
risk ; her life was miserable from pain, her health had given way, 
and she had to work that she might live. The case was now quite 
a clear one for interference, and I willingly agreed to try and remove 
the tumor, the patient clearly understanding that this might not be 
accomplished. 

On December 12th an incision, twelve or fifteen inches was made 
at once. The tumor was of a dusky-brown color, covered by enor- 
mous veins. It was firmly attached to the right iliac fossa, right 



394: DISEASES OF WOMEN. 

lumbar region, and to the wall from a little below the nmbiliens. 
This extent of adhesion qnite accounted for the fixed state which the 
tumor had always presented. Upward of four pints of a dirty, 
black, purulent-looking fluid were removed, the incision was en- 
larged, and with one strong pull of the arm, pushed in from behind, 
the adhesions were broken up and the tumor dragged out. So rap- 
idly was blood lost from huge, torn veins in the capsule, that she 
became faint. The left ovary only could be included in the wire 
ligature. From the previous elevation of the cervix, the stump was 
secured in the lower angle of the wound with less tension than in 
the first case. This part of the operation occupied only a few min- 
utes, but it was upward of two hours ere the wound was closed. 
Much trouble arose from stopping bleeding in the torn adhesions, 
more especially those high up on the insides of the ribs, near the 
posterior margin of the liver. A glass drainage-tube was left in, 
passing to the bottom of the pelvis. The patient was pulseless when 
placed in bed. This was an anxious operation on account of the 
unusual loss of blood. 

It is unnecessary to give details of the slow convalescence. The 
tube was removed on the fourth dsiy, and the whole amount of red 
serum that came away did not exceed three ounces. This could 
easily have been absorbed. The pulse had fallen to below 100 by 
the flfth day, and there was scarcely any disturbance of the tem- 
perature. There was, however, much flatulence during the second 
and third weeks, also much trouble with the bowels, and at one time 
there was a fear of obstructed intestine. It was thought — though 
there was no evidence of this — that there might have been some 
adhesion at the angles of the bowel, caused by the presence of the 
drainage-tube. As in the former case, the slough extended far be- 
yond the wire, and a large cavity was left on its separation. 

Six weeks later she went home. I saw her quite recently. She 
was in perfect health, and had been so ever since her operation, now 
nearly ten years ago. 

The application of electrolysis to the treatment of fibroids has 
been so thoroughly elaborated by Prof. George J. Engelmann, M. D., 
of St. Louis, that I have with his permission given here a few cases 
from his work on that subject : 

Uterine Fibro-myoma with Menorrhagia, Retro-uterine Hematocele, 
and Left Cellulitis. — The hsemorrhagic state of this case, the existing 
inflammation, which was active, subacute, contra-indicated electrol- 
ysis or negative electro -puncture. To check the hgemorrhage, posi- 
tive electro-cauterization was resorted to, the platinum sound con- 



t 



FIBROMA OF THE UTERUS. 395 

nected with the anode in the uterus, the large dispersing cathode 
upon the abdomen. At the first sitting a current of 60 milHamperes 
was used for eight minutes, no stronger current being admissible on 
account of the existing inflammation. The effect was good, haem- 
orrhage and pain lessened. Two days later the treatment was re- 
peated, 100 milHamperes used for six minutes ; bleeding, which had 
been almost constant, was stopped. After three further treatments 
upon alternate days, the menses appeared : previously profuse, now^ 
normal in quantity. This symptom being overcome, the inflamma- 
tory conditions were attacked by vagino-abdominal galvanism ; the 
negative pole, a large metallic ball covered with absorbent cotton, 
moistened in warm water applied per vagina, the large plate in con- 
nection with the positive pole upon the abdominal surface of the 
exudation. From 40 to 60 milHamperes were so used, serving to 
relieve the pain. Haemorrhage and excessive suffering being 
overcome, the patient was ordered to bed at her home, and di- 
rected to continue the use of poultices and hot- water injections 
until more active measures could be taken for the destruction of the 
tumor. 

Uterine Fibro-myoma (bilobar) extending to one finger's breadth 
above the navel. 

First tentative treatment, May 2d : negative electro-puncture ; 
small stylet introduced to the depth of 3 centimetres ; 80 miUiamperes 
for five minutes. 

Second puncture. May 5th : large platinum stylet introduced to 
the depth of 4 centimetres ; an intensity of 100 milHamperes for five 
minutes ; no pain was experienced from the internal electrode, and 
the abdominal burning diminished greatly toward the end of the 
sitting- 
Third sitting, after an easy menstrual period, May 12th : 80 mil- 
Hamperes, six minutes ; highest portion of the tumor 3^ centimetres 
below the navel. 

Fourth sitting, May 24th : 60 milHamperes, eight minutes ; large 
stylet introduced to the depth of 7 centimetres ; highest portion 5 
centimetres below navel. 

May 31st, notwithstanding that a current of only 60 milHamperes 
had been appHed on account of insufficiency of the battery, local pain 
followed, the tumor enlarged in circumference, extending above the 
navel, became tense, swollen, apparently fluctuating ; no rise of pulse 
or temperature. Treatment deferred. 

June 2d, fifth treatment : 50 milHamperes, six minutes ; tumor 
harder, less elastic, much diminished. 



396 DISEASES OF WOMEN. 

June Ttli, sixth treatment : large stylet, 8 centimetres, 60 milK- 
amperes, seven minutes. 

June 15th, seventh treatment : 60 milliamperes, ten minutes ; 
tumor very hard, extending half-way to umbihcus ; pelvis, which 
had at first been almost full, more free ; vagina, which had been a 
fan-like expansion, now assuming more normal proportions. Ice-bag 
immediately after treatment, since it had answered well when applied 
during the apparently inflammatory enlargement. The patient re- 
turned to her home after the ninth treatment greatly improved in 
health, functions re-established, the tumor reduced very much in 
size. Each of the nine sittings had lasted from five to ten minutes. 

Xrterine Fibro-myoma. — General debility, scanty menstruation. 
Patient aged thirty-two. A fibro-myoma, similar to the last, filling 
the pelvic cavity, its left half extending to the height of the navel, 
the right an inch and a half lower, the uterine cavity possessing a 
depth of 13 centimetres. This tumor, which had been first noticed 
in November, 1885, had been rapidly growing, notwithstanding 
active local and constitutional treatment, mainly with ergot, at the 
hands of one of our ablest gynecologists, first came under my ob- 
servation March 9, 1886, recommended to me by her previous attend- 
ant, my esteemed friend Prof. Boishniere. 

April 2Sth, first tentative treatment ; the puncture made with a 
small stylet ; a current of 45 milliamperes was used for five minutes. 
Treatment was continued once a week, the puncture hereafter being 
made with a large platinum stylet through the cervical tissue, and 
the prominent vaginal projections of both right and left masses, 
which were punctured to a depth of from 7 to 8 centimetres. For 
the six treatments following the first, a current of from 100 to 110 
milliamperes was used ; then a still higher intensity, from 160 to 
200, was applied. The burning, occasionally intense, often decreased 
to a minimum toward the end of the sitting (by reason of the anaes- 
thetic effect of the positive pole), the punk- and chamois-covered 
plate being used, leaving the abdomen, after its removal, sometimes 
slightly reddened, but always cool. This patient, feeble, subject to 
fevers, at first did not improve constitutionally. The tumor, after 
the third puncture, was 3 centimetres below the navel on the left 
side, 4 on the right — the pelvis more free, a most decided shrinkage, 
due, I presume, in part to the powerful contraction caused by the 
high intensity used. In this case free bleeding followed several of 
the applications, from one to six hours after treatment, after the 
fourth puncture ; coming at one time when still on the table, checked 
with considerable difiiculty by iron cotton tampons. By June 2Sth 



FIBROMA OF THE UTERUS. 397 

the tumor seemed again to increase ; her general condition not Lav- 
ing improved, menstruation still being excessively scant, a mere 
show, I endeavored to further constitutional improvement, using no 
internal remedies, as she complained of her stomach, which had 
been ruined by constant but ineffective medication ; electrolysis was 
stopped, and negative electro-cauterization resorted to for the pur- 
pose of increasing the flow. The uterine cavity then micasured 11 
centimetres. 

July 1st, negative electro-cauterization ; 100 milliamperes, six 
minutes. July 12th, 100 milliamperes, eight minutes. July 16th, 
150 milliamperes, ten minutes, no discomfort whatsoever being ex- 
perienced from the intra-uterine negative pole. 

August 6th, menses free, continuing five days ; more profuse and 
better than ever before since first established ; she has gained three 
and a half pounds in the last month ; looks much better ; feels well. 
This treatment was continued, with interruptions, during the sum- 
mer ; menses more free than they had been for years ; her general 
condition much improved. No medication whatsoever was re- 
sorted to. 



CHAPTER XXIL 

MALIGNANT DISEASE OF THE UTERUS. 

A VERY important, and a very frequent class of diseases is that in- 
cluded in the above term ; and for this, if for no other reason, must 
we have a clear notion of the terminology so often misapphed. 

Malignant growths are those which tend to infiltrate and destroy 
adjacent tissue, to recur after removal, possibly originate remote 
secondary neoplastic formations, and which cause steady deteriora- 
tion of the general health without regard to location. They are 
not necessarily " cancers." 

Cancer is an " atypical epithelial neoplasm," distinct from 
growths of the pure connective-tissue type. Its forms are few and 
pretty well settled and agreed npon. The first is scirrhus, hard, 
chronic, or fibrous cancer ; the second is soft, acute, medullar}^, or 
encephaloid cancer ; the third is colloid, " gum," or alveolar cancer ; 
but whether epithelioma is a fourth variety or is itself a distinct 
form is still a mooted question. 

Epithelioma is often intensely malignant ; and the terra " can- 
croid " is a safe one as it certainly is lUce a cancer. 

Another vexed question is whether cancer of the uterus is a local 
exhibition of a constitutional malady, or is at first local and only 
later infects the system generally. 

The same uterus may be the seat of several varieties of carci- 
noma; or, again, the neoplasm may change from one form into 
another as well without, as after, surgical interference. 

Sarcomata are malignant directly in proportion to the lowness of 
their organization. They are of the embryonal-tissue type. 

CANCER OF THE CERVIX. 

The body of the uterus is so seldom the seat of carcinosis that 
when the unqualified phrase " cancer of the uterus " is used, it 



MALIGNANT DISEASE OF THE UTERUS. 399 

means of tlie cervix. Malignant disease of the corpus will be con- 
sidered separately. 

Excepting epithelioma, scirrhus is the most frequent variety, 
says one class of gynecologists ; encephaloid, says the other. They 
are both right, for I believe the initial stage to be nearly always the 
hard carcinoma, which subsequently becomes soft and medullary ; 
and since it is only the later form that is apt to produce symptoms 
sufficiently marked for the patient to consult a physician, this may 
account for the supposed rarity of scirrhus, as compared with en- 
cephaloid cancer of the uterus. 

With this idea of the development of the neoplasm in view the 
pathology will be given. 

Pathology. — One lip of the cervix becomes hard, uneven, and 
hypertrophied, and the nodules, w^hich (probably) originate in the 
submucous tissue, subsequently ulcerate through the mucous mem- 
brane, which is now covered with vascular vegetations, especially 
near the orifice ; the opposite lip suffers an identical lesion, the cer- 
vical orifice enlarges and now the whole cervix is covered with veg- 
etations. 

The cellular tissue of the vaginal mucosa just beneath this fun- 
goid mass which projects into the vagina, becomes, in its turn, in- 
durated, uneven, and granulated, while, simultaneously, the muscu- 
lar coat of the cervix is being infiltrated with the growth. 

The mucous ulceration is frequently gangrenous, and a fetid 
fluid, containing shreds of dead connective tissue and portions of 
vessels which supplied the necrosed part, bathes the surface at the 
cervico- vaginal junction where the loss of continuity is best marked ; 
and thus a hob-nailed or fungating mass entirely takes the place of 
what we should normally feel upon a vaginal examination. In very 
rare cases the carcinomatous mass is removed in toto as a gangrenous 
slough, and then the ulcerated patch that remains is walled in by 
normal tissue. It is to all appearance, a phagedenic ulcer. 

Microscopically, a section of scirrhus shows small cavities (alve- 
oli) surrounded by thick fibrous stroma, and in the alveoli are only 
a few polyhedral cells. 

An encephaloid section exhibits a delicate and scanty frame- 
work surrounding large alveoli which are crowded with cells (many 
of which are fatty) in a milk-white fluid, the " cancer-juice." The 
section from such a tumor is light in color and mottled. In the ves- 
sels are plugs made up of cancer-cells and flbrin ; the walls of these 
vessels are pigmented and fatty. 

Either variety is melanotic, when the blood pigment in the 



400 DISEASES OF WOMEN. 

stroma and alveoli is so rich as to produce a deep brown or black 
hue. 

Finally, one of the rarest forms of carcinoma uteri is colloid can- 
cer ; the dilference between it and encephaloid (of which it is a 
modification) is that the cells enlarge and are filled with colloid ma- 
terial, the alveoli enlarge also, and as the stroma thins, one cavity 
communicates with another so that anfractuous spaces are formed 
filled with a transparent gum like substance. 

The pathological effects of cancer of the womb are many and 
important. It may extend to, and perforate through the vesical 
wall ; this occurs of tener than one out of three cases, and cystitis al- 
ways precedes the rupture. 

Yesi CO- vaginal fistulse are by no means uncommon, and here we 
shall often find severe gangrenous processes attending. 

Rectitis may be excited and the wall of the rectum be perfo- 
rated. These are not half so frequent as bladder lesions. When, 
however, both structures are opened there is a cloacal intercommu- 
nication of vagina, rectum, and bladder. 

When stenosis of the ureters results either from external press- 
ure or from thickening of their walls, we will find the kidney anae- 
mic and full of urine (hydronephrosis). 

The cellular tissue of the broad lio^ament and iliac fossae is infil- 
trated, and, later, undergoes purulent infiltration, frequently induc- 
ing peritonitis, while the vessels and lymphatics leading to such 
purulent collections are the seat of carcinomatous inflammation. 

The peritonaeum of Douglas's cul-de-sac is pushed upward and 
pseudo-membranes inclose the uterus both anteriorly and poste- 
riorly. • 

The subperitoneal connective tissue of the true pelvis is thick, 
hard, and adherent to the bones ; it may press on, and cause fatty 
changes in the sciatic and pelvic nerves. 

The body of the uterus may be infiltrated, the organ being as 
large as when pregnant. Its walls may measure one and one half 
inch in thickness. 

The tubes are rarely involved ; and if carcinoma be located at 
first solely in the cervix the ovaries always escape. 

AVhen cancer proliferates downward in the vaginal walls it forms 
numerous nodes, as far as the introitus vaginae, so that a physical 
examination will become diflacult or impossible. 



MALIGNANT DISEASE OF THE UTERUS. 401 



EPITHELIOMA OF THE CERVIX. 

Cancroid, formerly called rodent ulcer of the cervix, is not so 
malignant as scirrhns or enceplialoid carcinoma. It seems to be of 
a more local character than the other neoplasms of this group. 

It appears in one of two forms — as pavement-celled epithelioma 
or as cylindrical-celled epithelioma. Excepting colloid cancer, this 
last is the rarest form of uterine neoplasm. 

Pathology, — Pavement-celled epithelioma begins in the epithelia 
of the vaginal portion of the cervix, the tumor formed being waxy, 
slightly vascular in spots, and dry on its surface. The mass is fria- 
ble (" fragile cancer "), and on pressure we can squeeze out white 
worm-like plugs, composed of epithelial cells. 

I have occasionally found this variety to begin within the cervical 
canal, and extend outward (not downward), so that on exploration 
the mass could be scooped out, leaving the cervix a mere shell, its 
exterior or vaginal portion showing few if any signs of wq'N growth. 

The tumor is lobulated, and, when the lobules compress the ves- 
sels, gangrene results, and all that part of the cervix that is carcinom- 
atous may drop off, or a deep, crater-like ulcer is excavated whose 
edges are always nodular ; hence the term " ulcerating epithelioma." 

Squamous epithelioma extends to the body and fundus, but in 
general its spread is limited by the nearest chain of lymphatics. 

Microscopically, a tubular structure is often seen, the tubes being 
surrounded by a fibrous material, and probably originating from the 
culs-de sac of the cervical glands. 

The appearance of the section has given the name " cystic epi- 
thelioma" to it. When the tumors are crowded with lobulated nests 
of cells, connected together with epithelial bands, the centers are 
filled either with colloid matter or a hard mass resembling ordinaiy 
callous (such as that on the hand or foot). 

Cylinder-celled epithelioma originates as a pedunculated or ses- 
sile vascular wart; and, although the dendritic tumor begins in a 
single spot, it tends toward the vagina in its growth, and spreads 
downward as the so-called " cauliflower excrescence," often as lai'ge 
as a hen's egg^ and not rarely completely filling the vagina. 

The glands are so distended that the French pathologists call this 
" adeno-carcinoma." 

At first the cylinder cells of the cervical mucosa form a soft mass, 
with a milky juice ; thus it is hard to differentiate it from enceph- 
aloid except by the aid of the microscope. 

JM on-malignant papillomata also resemble these vegetating epi- 
27 ^ 



402 DISEASES OF WOMEI^. 

tbeliomata, and, without a microscropical examination, whether a 
cauliflower excrescence is or is not malignant can not be determined. 
With such an examination the non-malignant is seen to lie upon 
healthy submucous tissue, the malignant upon unhealthy ; the non- 
malignant is a simple anastomosing framework, while the malignant 
growth has an alveolar arrangement with cell-nests. 

This form of cancroid invariably ulcerates ; and, though occur- 
ring late in the disease, this process is rapid and destructive, large 
vessels often being eroded. 

Microscopically, it consists of numerous long stems, all intercon- 
nected, each stem having at its center a vascular loop, the exterior 
covering being long cylinder cells ; thus it is like an intestinal villus, 
only longer, and the numerous vessels among the masses of cells per- 
mit serum to ooze through their walls, and this is the chief source 
of the watery discharge of this disease. 

The points of secondary invasion are many ; the bones, lungs, 
liver, bladder, rectum, pelvic nerves, adjacent lymphatics, and the 
uterus have been the loci of later malignant growth, and in the 
uterus it occupies the tibro-muscular structure as numerous and par- 
tially distinct nodules. 

Symptomatology. — Malignant disease of the womb runs no typi- 
cal course. As with cancer elsewhere, so here there is a stage where 
a tumor is forming, and a stage where it ulcerates. 

During the first of these stages the amount of pain, the lencor- 
rhoea, and haemorrhage are so slight that few patients will consult 
the physician about them. And, as I have said, it is probably for 
this reason that scirrhus is considered a rare form of cancer. And 
let me say at the very outset that the lancinating pain so often men- 
tioned all through our literature as strongly symptomatic of carci- 
noma uteri is exceptionally met with in this disease. 

A discharge is the earliest symptom in the majority of cases. 
This discharge may be bloody, watery, or leucorrheal. As a rule 
it assumes the character of an intense monorrhagia, the patient also 
bleeding between the menstrual epochs either spontaneously or from 
sudden exercise or coition. Some women will state that although 
their change of life occurred a year or so ago, that now they have 
'' commenced again." 

The bloody discharge may or may not be fetid and grumons, but 
the organic matter which forms the grumous discharge, and which 
is continually sloughing away and passing out of the genitals, very 
seldom causes any septicaimia. Besides, the lymphatics are not here 
abundant in the immediate neighborhood of the cancerous tumor. 



maligna;n"t disease of the uterus. 403 

"VYatery discharges consist chiefly of the clear serum of the blood ; 
they are usually odorless at first, but soon become mingled with 
ulcerati\^e debris^ and are peculiarly foul smelling. They are seldom 
or never free from admixture of blood, and there are very few who 
will not give ^' bloody water " as one of their chief symptoms. 

The watery flux is almost characteristic of the cauliflower excres- 
cence. 

In many cases the discharge is simply leiicorrheal up to the time 
of ulceration of the cancer, after which the fetid " cancer smell " 
and molecular masses from the growth indicate the true cause of the 
discharge. 

A sudden bright haemorrhage indicates that a medium-sized ar- 
tery has been opened. 

The more rapidly the neoplasm forms, and the more extensively 
it ulcerates, the more profuse and fetid will be the discharge. 

Excoriations, erosions, erythema, vaginitis, vaginismus, intense 
pruritus, and similar conditions may result from the passage of these 
discharges through and over the genitals. 

Pain is never so prominent a symptom as the discharge, and, 
according to some, never a symptom so long as the cervix alone is 
the seat of malignant growth. The character of the pain is described 
diiferently by difl;erent patients, as dull, boring, gnawing, shooting, 
and stabbing. 

The pain shoots in the direction of the parts supplied by branches 
of the nerve whose main trunk is pressed upon. The back, pelvis, 
and thighs are the chief regions of this kind of pain. 

The pain is more acute when the terminal nervous branches are 
involved than when the trunk alone is compressed ; and it is, again, 
more severe when there is a large amount of neoplastic tissue formed 
than when ulceration is extensive. 

The pain of peritonitis, which may be lighted up by the grovrth, 
has characters peculiar to itself 

The amount of tenderness is not always in proportion to the 
pain. 

Pain on motion and from coition (dyspareunia) is experienced 
almost from the onset in neoplasms of the cervix ; later on, defeca- 
tion and urination may produce intolerable suffering. Pain as a 
symptom may be absent throughout the disease, and the patient only 
experience weight and bearing down. 

As the disease progresses, the patient first loses strength, appe- 
tite, and all cheerfulness of disposition, emaciation following later 
on. The face assumes an earthy green, or, toward the end, a bronzed 



404 



DISEASES OF WOMEN. 



a^ 



hue, and the temperature may be slightly subnormal. There is som- 
nolence and headache, but eclampsia is infrequent. 

The bowels are constipated, as a rule, but irritation or actual 
cancer of the rectum may cause profuse and exhaustive diarrhoea ; 
haemorrhoids are common. Cystitis, strangury, and retention or in- 
continence are not infrequent bladder symptoms. 

When fistulse form, they give rise to their usual symptoms. In 
one case the lirst, and, indeed, the symptom on which the diagnosis 
was made, was a flow of urine from the region of the cervix. 

The breasts are frequently the seat of sympathetic pain. Toward 

the close of the disease there 
is usually a slight febrile move- 
ment in contrast with the tem- 
perature in the early stages of 
the disease. 

Physical Signs. — Scirrhus 
carcinoma gives a hard, hob- 
nailed or nodular feel to the 
finger during the earliest sta- 
ges, and the mucosa seems to 
be immovably fixed on the sub- 
jacent connective tissue, a con- 
dition not met with except in 
malignant growths. 

When any cancer has ul- 
cerated (the usual time w^hen 
the physician sees it), the fin- 
ger meets a friable, irregular mass, which bleeds upon the slightest 
provocation, and which is surrounded by a tough, unyielding, irreg- 
ular zone of infiltrated tissue. If reached, the lips of the cervix are 
felt to be uneven, thick, and spreading downward like a mushroom. 
Palpation may further reveal in many cases fistulse, immobility 
of the womb, changes in the size and position, and infiltrations and 
indurations in the neighborhood. 

In scirrhus the womb is felt to be low down in the pelvis. 
The bowels may have been so constipated that the physician 
examines for stricture of the rectum before searching for anything 
else ; but in doing this he will directly suspect the true state of 
affairs, and especially so if the pelvic cellular tissue or neighboring 
glands be involved. 

A second physical sign, which is supposed by some to be diag- 
nostic, is that a sponge tent or uterine dilator fails to dilate a cervix 




Fig. 184. — Cancer of both lips (Winckel). 



MALIGNANT DISEASE OF THE UTERUS. 405 

snffering from malignant disease, whereas in all other neoplasms dila- 
tion will quickly and easily follow its introduction. 

A third physical sign is indescribable ; it is the odor that the 
finger has after such an examination — an odor produced by nothing 
else but cancer. 

A fourth means of physical diagnosis is the speculum, by the 
use of which we see w^hat has already been described under the head 
of pathology. Commencing scirrhus is accompanied by a deep pur- 
plish or livid hue of the entire cervix, and enlarged vessels are seen 
to ramify about these nodules. 

The extent of the growth can only be accurately appreciated by 
this means of examination. Epithelioma of the cervical cavity is 
often diagnosticated solely by the use of the speculum and curette 
or probe. 

Lastly, the microscope may be used not only to diagnosticate the 
presence or absence of carcinoma, but to decide which variety we 
have to deal with. It should be stated here that malignancy can 
not be decided by the microscope, since it is a clinical property. 

The microscopical appearances of each form have already been 
described. 

Diagnosis. — Before treating of the points in which cancer and 
other lesions of the uterus differ, it is necessary to mention the char- 
acters that especially distinguish one form of carcinoma from an- 
other. 

Scirrhus gives a nodular, hard sensation on palpation, immobility 
of mucosa upon sub-mucosa, prevents cervical dilatation on using 
the sponge tent or the uterine dilator, showing less of elasticity in 
the tissues, and the discharge is scanty. 

In medullary cancer the grumous discharge containing molecu- 
lar debris is the prominent symptom. The course of this cancer is 
the most acute of all. The brittle, crumbling, ulcerated mass is pe- 
culiar to this form. The uterus is usually fixed and immovable. 

Epithelioma is accompanied by a more profuse watery discharge 
than any other variety ; and on palpation the finger meets, often, 
the characteristic cauliflower-like mass. The uterus even late in the 
disease suffers no fixation, and may be moved without pain. This 
variety seems more local than the preceding. 

In all instances when cancer is diagnosticated a microscopical ex- 
amination will determine what variety we are dealing with ; and to 
this end a piece of the tumor may be removed by the curette. 

There are numberless conditions with which cancer in general 
may be confounded ; the chief of these are ; 



406 DISEASES OF "WOMEX. 

Sloughing Myomata or Fibrous Polypi. — These may, either of thenij 
simulate cancer; but they will be attended by fever which is absent 
in cancer, and there will be in the discharges shreds of the normal 
uterine tissue, while in cancer discharges, epithelial cells will be 
prominent. Frequent washings control the former while cancer re- 
mains unmodified thereby. 

Syphilitic Ulcer ation. — This not only resembles cancer but may 
even produce vesico-recto-vaginal fistulse. Here the history, the 
age of the patient, the effects of local and constitutional treatment, 
the discharge, and an examination of a small bit of the tumor, will 
soon allow a diagnosis to be reached. 

Condylomata. — These will not long be mistaken for cancer. 

Erosions. — These are numerous ; but non-malignant erosions oc- 
cur in younger patients, produce no constitutional symptoms, leave 
no portion of the cervix intact, are attended with large, gaping fis- 
sures and, on inspection by means of the speculum, large ovula JS'a- 
bothi are seen. The discharge does not have the cancerous odor in 
benign erosions. 

Diphtheritic and Other Intense Inflammations of the Mucosa. — These 
as well as retained portions of the membranes or placenta, have 
been mistaken for cancer ; here again the history, age, and the use 
of the speculum will decide. 

Benign Papillomata. — These are so small in size that only for a 
short time will they be mistaken for cauliflower excrescence. At 
all events the microscope will decide. 

The points in connection with cancer of the body and cancer of 
the cervix are considered hereafter. 

Prognosis. — It is needless to say that the invariable tendency of 
malignant uterine disease is toward death. The chief question in 
prognosis therefore is of the duration of life. There are no hard 
and fast rules for the expectation of hfe, nor do my own statistics 
or those of others afford definite statements. 

Three months and three years are the extreme figures given. 

In general it may be stated that, after the first marked symptom 
(some discharge), the patients live a year, except those who have 
epithelioma or cancroid ; these, as a rule, have eighteen months of 
life before them. 

JSTever make a prognosis immediately after diagnosticating can- 
cer, but wait until the disease pronounces itself a slow or rapid, an 
uncomplicated or a complicated, a localized or an extending process. 

Among the complications are hydronephrosis (see pathology), 
and, consequently, uraemia, cellulitis, and peritonitis, and, less fre- 



MALIGNANT DISEASE OF THE UTERUS. 407 

quently, septicaemia, phlebitis with venous thrombosis, embolism, 
and cancer in adjacent tissues and distant organs, the liver especially. 

Death may result from simple exhaustion (cancerous marasmus), 
or from haemorrhage when a large vessel is opened, or from rupt- 
ure of the uterus (rare), or from any of the above-named complica- 
tions. 

Death is sometimes delayed and torturing, and in the face of its 
being inevitable it often seems as though it were a mercy to hasten it. 

Etiology. — ^Until puberty the death-rate from cancer is the same 
in both sexes ; from this period both frequency and death-rate stead- 
ily increase in the female up to, and a little after, the menopause, at 
which period the difference in rate between the sexes is most marked. 
After the age of fifty there is a tendency for cancer to appear 
equally often in both sexes. 

There is no doubt but that there is such a condition as a predispo- 
sition to malignant disease ; but to what extent this can be inherited 
or not, is not yet determined. It is well known, however, that cer- 
tain peculiarities of organization predispose to malignant disease. 
Among these is the cardio-vascular hypoplasia (Yirchow), where the 
pulmonary arteries are undersized, and which occurs often with the 
phlegmatic temperament, characterized by an abundant adipose-tis- 
sue and an appearance of health, which is an appearance and noth- 
ing else. 

Great differences are met with in authorities as to the frequency 
of cancer ; reliable statistics, however, tell us that the uterus was at- 
tacked in three thousand cases out of a total of sixty-one thousand 
seven hundred and fifteen cases of carcinoma (anywhere in the 
body) in females. The same also afford us proof that the uterus is 
cancerous three times as often as any other female organ. 

Heredity has an undoubted influence ; I have gathered the sta- 
tistics of many thousand cases, and find that an inherited taint can 
be traced in thirteen per cent of all cases on an average. 

Age is the most potent factor in the etiology. Before puberty, 
indeed before the age of twenty, cancer is unknown or phenomenal. 
I have seen two cases — both ending fatally — where the patients 
were in their twenty-seventh and twenty-eighth year, respectively ; 
and the sister of the last named died of cancer of the uterus in her 
thirty- first year. 

The ten years following the menopause (forty to fifty) is the 
period of carcinoma uteri : the decade following this is the next 
most eventful period, and third in order stand the ten yeai's preced- 
ing the climacteric- 



408 DISEASES OF WOMEl!^. 

E-ace seems to have little or no influence. Perhaps it is pecul- 
iar to my practice, yet I have seen more cases of carcinoma uteri 
among Germans than in any other nationality. 

There is more than an accidental agreement between cancer and 
the number of children born ; for it will be found that patients with 
cancer of the uterus will average one third more children than 
women free from malignant disease of the womb ; indeed every 
case of carcinoma uteri will average five children, a large family 
at the present time. 

Prolonged lactation, anti-hygienic surroundings, poor or improper 
food, exhausting diseases, grief and anxiety, all are more apt to be 
accompanied by cancer than an opposite condition of affairs ; never- 
theless, seventy-five per cent of cases will give a history of good 
health up to the development of this neoplasm. 

It is quite certain that laceration or erosion of the cervix has a 
causative influence upon cancroid ; hence in suspected epithelioma 
the previous history must always be elicited. I do not mean that 
laceration will cause it ; but with a latent tendency, an erosion or 
laceration will often determine the precise point of eruption of the 
disease. 

Treatment, — This may be divided into constitutional and local ; 
and the local treatment consists in («), topical applications, and {h\ 
operative procedures. 

Constitutional treatment is always in order, and is always bene- 
ficial, but operative treatment demands the highest judgment ; used 
in season, surgical means may eradicate a growth that never reap- 
pears ; used when any tissue or part other than the uterus has become 
infected, an operation is useless for cure, and may, indeed, hasten 
the fatal termination. 

But, be it understood, there is only one means of actually treat- 
ing a patient with cancer, and that is to operate surgically, not merely 
to nurse her. 

Haemorrhage demands prompt treatment on account of the ex- 
haustion it induces. Astringent injections — hot better than cold — 
plugging of the vagina with small pieces of ice, or, rarely, plugs 
soaked in perchloride of iron, may be used. Tannic acid, rhatany, 
catechu, perchloride of iron, or ergot by the mouth or ergotine 
hypodermically I consider as inefficient, and are only mentioned here 
to be condemned. They are too frequently employed in practice. 

Pest, especially during menstruation, freedom from mental shock 
of any sort, and cessation of intercourse should be enjoined to pre- 
vent haemorrhage. 



MALIGNANT DISEASE OF THE UTERUS. 409 

Pain finally becomes intolerable. What shall be given? The 
easiest way to quell this symptom is by filling the patient with opium 
or morphine, the latter given hypodermically. 

Hydrate of chloral, while producing a more natural sleep than 
opium, does not seem to control the pain so well. Cannabis Indica 
and hyoscyamus are highly thought of by the French ; also vaginal 
pessaries of iodoform (fifteen grains). The hydrochlorate of cocaine 
is an efiicient local and general remedy for pain. 

The discharge is ofi:ensive, and the patients wish its fetor de- 
stroyed before demanding treatment for almost any other symptom. 

Condy's fluid, Labarraque's solution, carbolic acid, and its allies 
(thymol, phenol, etc.), bromine, lead acetate, or iodine — any of these 
will act antiseptically, and will in part deodorize the discharge. At 
the same time the amount of the discharge can be diminished by 
any astringent injection, such as alum, iron, zinc, lead, or copper, 
but tannic acid seems to have a specially favorable action upon the 
flux from cauliflower excrescences. 

The diet should be as simple as possible, yet composed of food 
in which there is a minimum of volume and a maximum of nutri- 
ment. A milk-diet is known to be so beneficial that the laity regard 
it as a " cancer cure." 

A moderate amount of alcohol should be taken daily with the 
meals. 

N^ext in importance to diet is the mental condition. The sur- 
roundings should be as pleasant as possible. The prognosis and diag- 
nosis need only be known to the immediate friends. 

Finally, certain symptoms, such as peritonitis, ulcerations, and 
erosions of the genitals, may call for treatment, which in no respect 
differs from that in non-cancerous cases. 

In the local treatment of carcinoma of the cervix the application 
of caustics is one of the first things tried by the inexperienced ; and 
it is the use of caustics for cancer anywhere that has become the 
pre-eminent means in the hands of the unprincipled. 

Pure nitric acid removes by a slough extensive portions of the 
diseased tissue, and simultaneously stops haemorrhage. The cervix 
should be washed and dried immediately before, and washed again 
immediately after the operation. 

Chromic acid, bromine solutions, acetic acid, perchloride of iron, 
and even gastric juice have been employed as caustics, and of this 
group I prefer the first named. 

Among the many remedies from which special benefits are said 
to accrue in the treatment of cancer is the milk of aveloz. In the 



410 DISEASES OF WOMEN. 

"IN'ew York Medical E-ecord," of July 11, 1887, is a report on this 
drug, made bj Dr. James B. Hunter, from which I make the fol- 
lowing abstract : 

" The milk of aveloz is the product of a plant growing in Brazil, 
one of the Etijphorl)iacem, many varieties of which are well known 
for their irritant and acrid juices. Dr. Hunter had not been able, 
from any botanical works at his disposal, to ascertain exactly the 
position of the plant furnishing the juice known as the milk of aveloz, 
but it appeared to be closely allied to the Ilura crepitans, the milk of 
which is described by the older botanists as possessing extraordinary 
properties as an irritant. 

"Boussingault made an examination of some of the juice, and 
was attacked, he says, with a severe form of erysipelas. The courier 
who brought the juice, as well as the inhabitants of the house in 
which he spent the night on his way, were also attacked with severe 
inflammation of the skin. Another species of the same family grow- 
ing in Brazil is the Hippomane rnancinella, or manchineel tree, 
about which there are fabulous accounts, as that it is fatal to life to 
sleep beneath its shade. It is true, however, that a drop of the juice 
of that tree applied to the skin will quickly i-aise a blister full of 
serum. It is not surprising, therefore, that the milk of one of the 
Eujphorhia family should be possessed of very active properties. 

" Several years ago a small quantity of the milk of aveloz was 
sent from Brazil to the authorities at Washington, and distributed 
for trial. Then for a time none could be obtained. Later it was 
to be purchased of a gentlemen in this city — John T. Kirby, 16 
Beaver Street. The depot for its sale is in Pernambuco, the juice 
being collected chiefly in the province of that name. The prepara- 
tion is said to be patented by the Government of Brazil, and its use 
is indorsed by the Central Board of Health of Rio de Janeiro. 

" Two preparations are furnished, one of which is recommended 
for open ulcers, and the ether for cases of cancer in its early stages. 
The principal or only aj)preciable difference appears to be in the 
degree of inspissation. 

" The method of using the drug advised is, that the affected sur- 
face be thoroughly cleaned with a carbolic lotion, and dried. The 
juice is then applied freely with a soft brush, retained in place 
by lint or cotton, and covered with light rubber or gutta-percha tis- 
sue. The purpose of the application is to produce the effect of a 
caustic. Special care is necessary to prevent contact with sound tis- 
sues, as it is extremely irritating. The application is repeated every 
three or six days, according to the condition. Dr. Hunter's experience 



MALIGNANT DISEASE OF THE UTERUS. 411 

liad been confined to cases of epithelioma of the cervix. He first 
aUuded briefly to the experience of others. Its application to dis- 
ease of the breast is said to be very painful. There is not "usually 
much pain in its use on the cervix uteri." 

During the past three years Dr. Hunter has applied the milk of 
aveloz in many cases of epithelioma of the cervix, and, though its 
eSect had often been negative, in a certain number it had produced 
results that he had not obtained by any other means. In cases of 
spongy, easily disintegrated crevices, it had left a better surface than 
nitric or chromic acids, or than the actual cautery. It had also 
seemed to him that the recurrence was delayed longer than after the 
ordinary caustics. He had confined its use to cases where the knife 
was not applicable, or where operation was not allowed. In some 
cases he had been surprised at the comparatively healthy condition 
of the surface remaining after the eschar came away, and surprised 
also at the long interval that elapsed before there was fresh breaking 
down. 

One of the effects of a free application of the juice to a diseased 
surface is to promote a copious serous discharge, thus depleting the 
congested vessels. In some cases a marked difference has been ef- 
fected in the character of the discharge, which has become and re- 
mained for a long time almost inofEensive. 

Cases which the doctor related illustrated the treatment and its 
results, which he described as follows : " All that could be said was, 
that they were in some respects better, as to the arrest of the disease 
and as to the comfort of the patients during its progress, than those 
afforded by many of the usual methods. As far as he could judge 
at present, he should not use the aveloz with any expectation of 
effecting a cure; but it seems probable that it may do more than 
some other remedies toward arresting the progress of the disease, 
and perhaps prolonging the period during which surgical treatment 
may be employed with some hope or promise of success. 

" He had not lost sight of the fact that some cases of cancer of 
the uterus undergo changes in their progress that might erroneously 
be attributed to the remedies used ; but, after making due allowance 
for that source of error, there still remains something to be said in 
favor of the drug in question." 

I have myself had no experience with aveloz, nor should I men- 
tion it here did it not have the indorsement of so good an authority 
as Dr. Hunter. 

Caustics seem to have a temporary good effect, but I think the 
activity they excite may produce an extension of the neoplasm itseK. 



412 DISEASES OF WOMEN. 

Interstitial injections of solutions — zinc cliloride, and carbolic 
acid, have been tried with varying success. 

Paquelin's thermocautery or the hot iron (the parts around being 
protected) may be substituted for caustics, or they may be used to 
stop haemorrhage with, or aid in closing over, any sound surface 
after any operation 

Simon's scoop, the sharp spoon, the curette, or even the finger- 
nail may be used to rapidly and completely remove soft, villous, 
semi-putrid masses, for then the consistency is such that other means 
can not be employed, a firm hold with an instrument being impos- 
sible. 

The scooping should be thorough, and performed antisepticaily. 
It causes greater haemorrhage than any other operation ; but bleed- 
ing may be checked by any of the above-named methods. Yet 
if done rapidly it is possible that powerful cauterization after a thor- 
ough scooping may completely arrest the progress of the disease. 
Sims's operation consists in scooping out the epithelioma (for it is 
epithelioma that this method is especially intended to remove) with 
the sharp spoon or curette, or cutting it down with a scissors or 
knife, and then scooping every particle of diseased tissue away. 
After thorough drying of the parts they are plugged with pledgets 
that have been soaked in saturated alum- water to which carbolic acid 
has been added (1-40), or in persulphate of iron, two thirds water, 
and squeezed dry after such soaking. The plugs are removed in 
live days and then wadding, soaked in a chloride-of-zinc solution, 
and squeezed dry, is packed into the cavity. This is very painful. 
Five days later this plug is removed ; and the slough denudes a 
granulating surface which will heal, Sims claims, within two weeks. 

This method is best adapted to cases in which the disease is 
limited to the cavity of the cervix. 

A modification of this I have frequently practiced in the class 
of cases referred to ; I thoroughly and very rapidly remove all the 
diseased tissue with a curette, and then plug the cavity wdth cotton 
and allow this plug to remain twenty-four to fortyeight hours. 
It is then removed and the surface thoroughly cauterized with Pa- 
quelin's thermo-cautery or the galvano-cautery. In case tlie bleed- 
mg subsides promptly after using the curette, the parts are sponged 
and pledgets of cotton saturated in zinc chloride are apphed, and a 
dry tampon of absorbent cotton is placed in the vagina to take up 
any of the zinc solution that may be squeezed out of the cotton by 
contraction of the parts. This dressing is removed in about forty- 
eight hours, and then the patient is kept at rest until the slough 



MALIGNANT DISEASE OE THE UTERUS. 413 

separates ; and if any suspicious-looking tissue remains, it may be 
touclied with the cautery. 

Amputation of the cervix is the chief means at our disposal for 
the treatment of malignant disease of this portion of the uterus. 

The contraindications are: When the neighboring glands are 
involved ; when (the vaginal portion of the cervix being healthy) 
the vagina is invaded ; and when the cancer closely approaches, or 
has reached, the junction of body and cervix. 

The importance of a thorough physical examination before de- 
ciding to operate is therefore seK- evident. 

The ecraseior is seldom used for amputation of the cervix. It is 
very painful, and on the lower sui-face of the cervix we may not 
reach the limits of the cancer, while above, the chain may include a 
part of the vagina. 

Galvano-cautery demands the same preliminaries and cares as re- 
moval by the ecraseur. I prefer Sims's position to the lithotomy 
position so often advised for this operation. 

Thomas's forceps grip the whole cervix and their projections 
prevent slipping of the wire. 

When the wire fits the line of demarkation, the operator should 
make the current and tighten the wire very slowly, gently pulling 
on the forceps as the wire burns deeper ; by this means the tissues 
will be made to assume a funnel-shaped appearance as they retract. 
A careful examination for diseased tissue should now be made, and 
should such be found it can be removed with the galvano-cautery 
knife, or the dome cautery may be employed to remove any suspi- 
cious tissue. 

The Germans do not regard either of these methods as compara- 
ble with removal by means of the knife. For, it is claimed, they 
confine the operator to one cut, whereas the knife can follow the 
borders of the new tissue however irregular they may be. But I 
am satisfied that the loss of blood and the uncertainty of manipula- 
tion from the haemorrhage, render it far more likely that diseased 
tissue will be missed in this operation than when the galvano-cautery 
is employed. 

Schroeder's operation for removal of the vaginal portion of the 
cervix consists in cutting both sides of the cervix so as to make two 
lips — anterior and posterior — and then excising a wedge-shaped por- 
tion from each ; the flaps are then stitched together and the incisions 
first made are last of all closed by sutures. 

This operation is only apph cable to those cases seen very early in 
the disease. 



414 DISEASES OF WOMEN. 

Scliroeder's supra-vaginal operation consists in cutting through 
the vaginal mucous membrane at the anterior fornix, the cervix 
being pulled down and firmly held, separating the bladder up to 
the utero-vesical poucli of peritonseum, then carrying the cervix 
forward and cutting the mucous membrane of the posterior fornix 
in a like manner. 

Some regard injury to Douglas's cul-de-sac as dangerous ; others 
claim that the pouch can be cut into and some of the peritonaeum 
removed with the tumor. 

The next step is to cut with knife or scissors above the lateral 
fornices, taking care to avoid wounding the brandies of the uterine 
artery. Thus, we see great care must be taken in the preliminary 
clearing away of the cervix. 

The operator now cuts through the anterior cervical wall in the 
healthy tissue above the tumor, opens the cervical cavity, and stitches 
the anterior vaginal wall to the anterior wall of the cervix. The 
cervix thus being held in place it is amputated when the knife 
passes through the posterior wall which is to be stitched to the pos- 
terior vaginal wall. 

The lateral wounds are closed with deep sutures which are meant 
to diminish the opening into the pelvic connective tissue, and to ar- 
rest haemorrhage. 

Should the vagina be affected it is to be severed at the distance 
of haK an inch from the carcinoma. 

Baker, of Boston, advocates a " high amputation," which is 
meant for a substitute for the entire removal of the uterus by 
Freund's or Scliroeder's methods. It is claimed for it that more of 
the uterus can be removed than by any other amputation ; that it is 
far more practical for the general practitioner than vaginal hyste- 
rectomy ; that more recoveries follow and fewer recurrences of the 
neoplasm have been observed. The patient is placed in Sims's po- 
sition, the cervix is pulled down to the outlet, and the supra-vaginal 
cervix is separated from the bladder in front, and the peritonasum 
behind, up to the internal os. These two incisions are connected 
by lateral cuts ; and then a funnel-shaped portion of the body is 
removed by the nterotome. As the incision begins much higher 
than in Sims's operation, we can remove not only the entire cervix, 
but almost haK the body of the uterus. Actual cautery — red heat 
— is applied to the whole denuded surface ; and no tampon is em- 
ployed to control the hgemorrhage. 

One of the most daring advances in gynecology is the introduc- 
tion of an operation invented and performed by W. A. Freund, hence 



MALIGNANT DISEASE OF THE UTERUS. 415 

called " Freund's operation " ; it is the extirpation of the entire 
uterus. 

Excision of the uterus is appropriate when cervical malignant 
growths are extending or threaten to extend upward, or when there 
is actual disease of the body. 

Freund's operation — by abdominal incision — is as follows : The 
incision is made from the umbilicus to the symphysis pubis, and the 
intestines are held up toward the diaphragm by warm, fine-linen 
cloths (soaked in some antiseptic solution) from the beginning to the 
end of the operation. The recti abdominales are separated so that 
the pelvis can be thoroughly inspected. The parietal peritongeum 
is stitched to the abdominal coverings, or a thread is passed through 
the fundus uteri, and another through the peritonaeum of the anterior 
part of the pelvis, both threads being held by assistants. 

The uterus is grasped by forceps — Freund's or any good instru- 
ment may be used — drawn upward, and three ligatures are then 
applied to each broad ligament. These ligatures are called the upper, 
middle, and lower, the two upper passing through the broad liga- 
ment, while the lowest includes the parametrium laterally, and with 
it the uterine arteries and the vaginal vault. 

In detail, the first suture — double silk — passes through the ova- 
rian ligament from behind, and through the broad ligament just 
below the free margin, in order that the ovarian artery may be in- 
cluded when this loop is tied. 

The second ligature passes through the ovarian ligament along- 
side of the first, and then through the round ligament, so that a 
second loop is formed, which, tied anteriorly, controls the pampini- 
form plexus. 

The third suture is best carried by a special needle designed by 
Freund, which is guarded by a trocar. So sheathed, it follows the 
finger of the operator in the vagina, pierces the vaginal wall twice 
— first through the antero-lateral portion of the vaginal roof into 
the vagina, and (secondly) back through the postero-lateral part of 
the vaginal cul-de-sac — behind the base of the lateial ligament, into 
the pouch of Douglas. 

The lateral fornix is pierced twice with this needle by grasping 
the free end of the double thread as soon as the first penetration is 
made, and holding it while the needle, pulled backward, runs on the 
thread, and thus can carry the suture a second time through the lat- 
eral fornix. The thread is cut beyond the eye of the needle after 
this last manoeuvre, and the end cut is carried through the round 
ligament completing this ligature, and controlling the uterine ai'terv. 



4:16 DISEASES OF WOMEN". 

A catheter in the bladder serves partly as a guide to the next 
step, which commences the excision of the organ. The utero-vesical 
pouch is cut through, and the peritonaeum resting on the bladder is 
sewed to the subjacent tissue. 

The peritonaeum of Douglas's cul-de-saG is cut and treated in a 
similar manner. Freund separates the cellular tissue with the finger 
in preference to an instrument. Finally, each broad ligament is cut 
internal to the three ligatures, and the uterus is removed. The ends 
of the ligatures are drawn into the vagina, the intestines are replaced, 
and all subsequent treatment is as after ovariotomy. 

Only a little over twenty-five per cent of recoveries after this 
operation have been recorded. Haemorrhage may be particularly 
severe, and with shock and possible inclusion of the ureter, it is one 
of the dangerous sequelae of ablation of the uterus by Freund's 
method. 

Schroeder has modified and, I think, improved Freund's opera- 
tion, which, according to the former, is thus performed. While the 
uterus is firmly held down in the vagina as close to the vulva as 
possible, the first cut is made through the utero-vesical pouch, but 
the peritonaeum is not injured. 

The next step is to free the cervix behind, and open into the 
pouch of Douglas. Two fingers are then passed into the last cut, 
and brought forward over the fundus down into the vesico-uterine 
pouch, and, while they are in this position, the peritonaeum is di- 
vided. The fingers, thus hooked over the fundus, retrofiex it, unless 
the uterus is very unyielding or hard, or the vagina is very small, 
and pull it out through the posterior wound. Sometimes forceps 
are necessary to do this. Each broad ligament is ligated in two 
places, and a third ligature encircles the whole. 

The uterus is now cut free from everything, and the two pedicles 
are brought into the vaginal wound, each being sutured to both the 
anterior and posterior fornix. 

A drainage-tube is inserted into the cavity of the peritonaeum 
between the stumps. 

The vagina is packed with antiseptic dressing. Finally, the 
sutures are removed in from ten to twelve days. 

Schroeder claims the same percentage of recoveries (seventy-five 
per cent) as Freund's statistics exhibit for deaths. 

From the frightful mortality of Freund's abdominal method, it 
has come to be almost abandoned, and vaginal hysterectomy — ^just 
described in detail — has taken its place. 

Statistics regarding vaginal hysterectomy are not reliable, nor as 



MALIGNANT DISEASE OF THE UTERUS. 417 

yet very usef al, first, because unsuccessful cases are seldom reported, 
audj secondly, because only a small number of cases at best have been 
published. 

Schroeder says if one person out of twenty be cured, this ought 
to be considered a good result. He also admits that recurrence is 
frequent after vaginal extirpation. 

If ablation of the entire organ by Schroeder's method should be 
performed only when cancer affects the body, or in those cases 
where it is limited to the cervical mucosa, and, in either case, when 
the vagina is capacious enough not to oppose difficulties to the 
operation, then I think it will be a most difficult matter to decide 
when to perform vaginal hysterectomy, for it is doubtful if the 
touch can determine infiltration of the lymphatics. At the present 
day there are no known ante-mortem means of determining with 
certainty whether the uterus is or is not the sole locus of malignant 
disease. Again, when cancer is limited to the cervical mucosa, its 
detection is very rare. 

It would seem that vaginal hysterectomy, according to Schroed- 
er's own statements, is destined to become a rare operation. 



CANCER OF THE BODY OF THE UTERUS. 

This condition, though rare as compared with carcinoma of the 
cervix, is by no means a phenomenon. 

* Pathology. — In corporeal epithelioma the epithelium of the 
uterine glands undergoes hypertrophy, and tliere is formed a f ungat- 
ing polypoidal mass, which propagates itself over all the organ, or 
projects into its cavity, perhaps into the cavity of the cervix. 

The cancerous mass always ulcerates and leaves v/ide cavities in 
the hardened uterine wall. The organ is enlarged. 

Scirrhus or encephaloid may, in rare cases, be found in the body 
of the womb, although the best authorities state that there is scarcely 
an unquestionable case of corporeal encephaloid, and that scirrhus 
has never been met with. 

These varieties form beneath the mucosa in the substance of the 
uterine tissue, and extend outward, causing peritonitis and agglutina- 
tion with neighboring organs and parts. When they extend inward 
they are certain to ulcerate. 

Either form of cancer, when accompanying fibroids, does not 
seem to modify the iatter's characteristicSo One case is recorded of 
cauliflower excrescence of the fundus ; this projected out through 
the cervix down into the vagina. 
28 



418 DISEASES OF WOMEiT. 

The microscopical appearances in no wise differ from similar 
neoplasms in the cervix {q. v.). 

Symptomatology. — The prominent symptoms of cancer of the 
cervix {q. v.) are also met with in cancer of the hody, but not to the 
same degree nor appearing in the same order. 

Pain occurs early, and is severe and paroxysmal, sometimes re- 
maining at its pitch for two hours. Intense menorrhagia is soon 
accompanied by a discharge which is profuse, watery, and fetid. In 
some instances there will be no discharge whatever throughout the 
disease. The vital forces are early greatly depreciated, and marked 
constitutional disturbance is a prominent early symptom of cancer 
of the corpus. 

Physical Signs. — Inspection gives negative results. On palpa- 
tion (bimanual) the body is felt to be larger and harder than normal. 
The cervix is usually dilated, but in a few instances has been felt 
to be normal. Adhesions may firmly hold the uterus in a fixed posi- 
tion, or just as often it is freely movable. 

On dilating the os with sponge-tent or finger, uterine tenesmus 
results, and, if we can enter the organ, the finger readily recognizes 
the condition of affairs within the corporeal cavity. 

The probe induces profuse haemorrhage in nearly all cases, and 
by its use we learn the degree of dilatation of the cavity of the 
womb. 

The curette is used to withdraw some of the growth for micro- 
scropical examination. * 

Diagnosis. — Cancer of the body and cancer of the cervix may 
be confounded with each other. The points that enable us to dis- 
tinguish them are these : Cancer of the body is very rare ; that of 
the cervix comparatively common ; pain is very early and very severe 
in cancer of the body ; it is rare or absent in cervical cancer. Men- 
struation is deranged from the very onset in cancer of the body ; 
this is a late symptom when the cervix is attacked. 

Marked constitutional disturbance and peritonitis — which is often 
fatal — occur early and more frequently in cases where the body is 
the seat of malignant growth than when the cervix is involved. 
There is little or no tenesmus on bimanual examination in cancer 
of the cervix, while this is marked in cancer of the body. The 
probe discovers an enlarged corpus in the latter case, while in cancer 
of the ceiwix the corpus is normal in size. The adjoining structures 
are implicated far more frequently, and also earlier in the disease, 
in cancer of the body than in cancer of the cervix. 

Prognosis, — The same rules hold good here as in cancer of the 



MALIGNANT DISEASE OF THE UTERUS. 419 

cervix. The outlook for recovery is far less favorable, not only from 
the situation of the growth and the greater likelihood of adjacent 
tissues being involved, but also from the fact that, as total extirpa- 
tion is the sole means of treatment, the probability of life after this 
operation is much less than after amputation, cautery, or scooping. 

Causation. — The body of the uterus is attacked with cancer very 
much more frequently in nulliparae than in multiparse, which is in 
striking contrast with the prevalence of cancer of the cervix. The 
average age of patients suffering corporeal carcinoma is ten years 
greater than that of women afflicted with cancer of the cervix. In 
every other respect the causation is the same as in cervical cancer. 

Treatment. — Extirpation is the sole means of effecting a cure in 
cancer of the body, and hysterectomy seems to be followed by far 
better results in these cases than when performed for cancer of the 
cervix. This may be accounted for on the ground that in the neigh- 
borhood of the cervix there is far greater liability to extension of 
the disease and infiltration downward and laterally. 



SARCOMA OF THE UTERUS. 

Fibroplastic tumors or " recurrent fibroids," are neoplasms of the 
embryonic tissue type whose seat is usually in the body of the 
uterus. 

Pathology. — The connective tissue is the origin of uterine sarco- 
ma ; and immediately beneath the epithehum this tissue forms 
nodules or ridges which bulge out the softened and somewhat dis- 
integrated mucosa into the uterine cavity. 

Since the projections are often polypoidal, pedunculated, soft, 
and medullary in consistence, rapid in their growth, and vascular, it 
is easy to see how they can be mistaken for carcinoma. Indeed, 
Klebs has found a profuse epithelial growth upon sarcomatous nod- 
ules of the uterus and then the growths seem to have joined. 

The uterus may be greatly distended by the fungus-like growth. 

When the mucous membrane is wholly disintegrated, the uterus 
may be perforated, and in rare instances the sarcoma may prolifer- 
ate out through the abdomen. 

In other cases the growth is deeper, less diffuse, and more nodu- 
lar. It begins anywhere in the uterine tissue between the submu- 
cous layer and the peritoneal investment and forms a hard, roundish 
mass like a fibroid. This may assume a fungoid or polypoid form 
and hang down in the uterine cavity ; as in cancer, so here, the soft 
may be a later stage of the hard sarcoma. 



420 rriSEASES OF WOMEK 

Possibly a degenerating fibroid of the uterus may be associated 
with a sarcoma ; or, as it then would be called a hbro-sarcoma. 

Microscopically, the round or spindle-shaped cells are seen 
crowding the section, the former, as a rule, being the ordinary vari- 
ety found in the uterus. The tumor is permeated with a meshwork 
of wide but thin- walled blood-vessels characteristic of this neoplasm. 

When the round cells are very large there is giant-celled sar- 
coma, or myeloid sarcoma. 

As to the effects, the vagina, peritonseum. Fallopian tubes, and 
ovaries may be invaded by sarcomatous masses. 

The uterus is often inverted, either from an easily dilated cervix 
or from weakening or palsy of the uterine muscle. 

Symptomatology. — The classical symptoms of malignant disease — 
pain, hsemorrhage, and discharge — are met in cases of sarcoma uteri. 

Pain, however, occurs late, if at all, and seems to have often 
been confounded with uterine tenesmus which is a common symp- 
tom. At times there may be severe pain from pressure on the rec- 
tum and bladder. 

Menorrhagia is an early symptom ; or if the disease is in those 
who have passed the menopause, menstruation seems to have re- 
turned. Later, there is a discharge resembling the rice-water stools 
of cholera which is only faintly suggestive of the cancerous odor. 
But as the neoplasm ulcerates, the discharge is as fetid as that of 
carcinoma, and in it are pale-gray shreds which, npon microscopical 
examination, at once reveal the true nature of the growth. 

A cachexia is very slowly and gradually developed, yet finally it 
is as marked as in cancer. 

Physical Signs. — Palpation reveals a soft, friable, pedunculated 
tumor which may be felt to spring from the body of the uterus. 
The OS, through which this tumor is forced is dilated, softened, and 
irregular. The finger or the sponge-tent may be used to dilate the 
cervical canal when the mass has not yet made its way down to the 
OS internum. 

Bimanual palpation shows the uterus to be large, sometimes 
reaching half-way to the umbilicus, and oftentimes as irregular as 
when the seat of fibromata. 

The sound shows the extent of the enlargements ; its use causes 
intense menorrhagia. 

The curette is useful to obtain scrapings for microscopic exami- 
nation. 

Diagnosis. — Sarcoma may be mistaken for carcinoma; but in 
the latter disease pain is a far more frequent, early, and severe symp- 



MALIGNANT DISEASE OF THE UTERUS. 421 

torn ; the discharge is fetid ahuost from the very onset ; the cervix 
is most difficult to dilate with a sponge-tent ; the constitutional 
symptoms are more severe ; and the duration of the disease is rarely 
over a year. These symptoms are in contrast with what occurs in 
sarcoma. 

Finally, a microscopic examination of some of the scrapings will 
always be necessary before determining the diagnosis. 

Prognosis, — Although a patient with sarcoma of the uterus 
lives on the average three or four years after the tumor is fairly de- 
veloped, yet the outlook for ultimate recovery is most grave, all cases 
slowly but surely tending toward a fatal issue. 

Sarcoma tends to reappear after most careful removal, although 
the time elapsing between removal and recurrence is much longer 
than in the case of carcinoma. 

The prognosis will greatly depend upon an examination of the 
scrapings — when these show scanty stroma with an abundance of 
cell elements the course will probably be as rapid as that of enceph- 
aloid cancer, but when the cells are few and the fibrous tissue is 
abundant life may be prolonged for six or eight years. 

Among the complications are septicaemia, ansemia, peritonitis, 
and sarcomatous nodules in adjacent organs. 

Causation, — Age is the chief predisposing cause ; half of all the 
cases occur between the ages of forty and iifty, and before thirty or 
after sixty, sarcoma is extremely rare. 

In cancer I referred to the occurrence of the disease in those 
who had borne many children ; but sarcoma seems to develop in 
sterile wombs in nearly fifty per cent of the recorded cases. 

It is a mooted question whether traumatism and uterine inflam- 
mation have any influence in the causation of sarcomata. 

Treatment. — When pedunculated tumors project into, or out 
through the cervix, the sharp spoon or the galvano-cautery or even 
the finger-nail may be used to remove them. Then carbolic or 
nitric acid may be applied to the base of the tumor. 

When the growth is not sessile but apparently superficial, 
thorough curetting and the application of nitric or carbolic acid are 
advocated. 

Deep sarcomata can only be treated by extirpation of the uterus. 



CHAPTER XXIIL 

THE MENOPAUSE. 

The menstrual function is permanently suspended about the age 
of forty-five years. This change in the habit, which is so important 
in middle life, is known by several names, such as the change of 
life, the climacteria, critical time, turn of life, and the menopause. I 
prefer the latter term as it best expresses that which takes place. 

Although forty-five is the average age at which this change takes 
place, there is very great variation in regard to time. The cessa- 
tion of menstruation has occurred as early as twenty-one, and as 
late as sixty-one years of age, but such cases are rare exceptions, and 
may be looked upon as curiosities and altogether abnormal. 

The limits of variation which appear to be in keeping with 
health, and hence may be considered normal, are at forty and fifty 
years. The change comes in the vast majority between forty and fifty 
years, and those who come within that space of time may be consid- 
ered as normal unless there is some morbid state accompanying the 
change, which may influence it. 

While marked variation in time is not incompatible with health 
it should be noticed that when there is a marked deviation from the 
average time, forty-five years, there is always a possibility of some 
morbid state being present which is the cause of the deviation. TJiis 
point should be investigated in all cases. 

Natural History of the Menopause. — The changes which occur in 
the organs of generation at the menopause constitute a complete in- 
volution, and are in marked contrast to those which take place in 
evolution of puberty. 

The two processes, the one the beginning, the other the end of 
functional life, are completely opposite in character, and yet, in 
some of their manifestations and effects upon the general system, 
they have many features in common. 

The menopause in the limited sense of the term indicates the 



THE MENOPAUSE. 423 

cessation of the menstrual function, but in the whole process of in- 
volution which constitutes the " change of life," there are two 
stages. The first extends from the beginning of involution and the 
decline of functional activity, the precessation period ; and the sec- 
ond which extends from the time that menstruation ends to the 
completion of involution and the adaptation of the general system 
to the new order of things, the post-cessation period. 

The changes of structure which take place at the menopause, 
are atropliic in character. The ovaries gradually diminish in size, 
and the Graafian follicles disappear, at least it is difficult to find 
them. When the involution of the ovaries is complete, there is 
little left of them in some cases, except a small mass of fibrous and 
cellular tissue, to indicate where they have been. Similar changes 
take place in the Fallopian tubes, uterus, and vagina. The tubes 
contract and become obliterated, the uterus is reduced to the size 
and something of the shape of the infantile uterus, and the vagina 
becomes shorter and narrower. 

The change in the blood-vessels is also quite marked. The ves- 
sels contract until the evidence of vascularity of the pelvic organs 
which exists in middle life, is almost obliterated. 

This involution in structure takes place slowly, as a rule, but 
when completed the sexual organs are reduced by atrophy to the 
rudimentary state, and are quite anaemic. 

During the precessation stage, while the flow is gradually dimin- 
ishing, or coming at irregular intervals, and also, for some time, 
during the post-cessation time, there are some disorders of the nutri- 
tive and nervous system which occur in the most healthy women, 
but they are of such a trivial nature that they are borne without 
attention being called to them. They expect some discomfort at 
that time of life, and the system soon adapting itself to the new or- 
der of things, complete harmony of action is established, and future 
good health follows. 

Of course, the rearrangement of the system takes more time 
with some than with others, and the degree of discomfort attending 
the change varies greatly, so that the line of demarkation between 
the normal and morbid is narrow and ill-defined. 

In the majority of healthy women there are usually some dis- 
turbances of the nervous system, and the organs of general nu- 
trition. 

The chief symptoms presented by the nervous system are occa- 
sional headaches, irregular flushing of the face, sudden changes in 
the temperature of the hands and feet, general irritability of the 



42i DISEASES OF WOMEN". 

nervous system, and torpor or sluggishness of the brain. These, with 
a great variety of other symptoms, are not sufficient to greatly dis- 
tress the patient and yet are quite enough to be noticed. 

There are often some gastro- intestinal disturbance and impaired 
ultimate nutrition, so that patients suffering in this way complain 
of indigestion. Such symptoms not only appear during the decline 
of the menstrual function but continue during the post-cessation 
period. 

Those who have observed most carefully the resemblance in cer- 
tain ways between puberty and the menopause, claim that those 
who suffer at puberty are liable to do so at the menopause. This is 
often the case, no doubt, as those who begin wrong are likely to end 
in a similar manner. 

Provision is made at puberty for the menstrual function, as has 
already been pointed out, and it may be briefly stated that a like 
provision is made in women in health for giving up that function. 

During involution, and especially after the cessation of menstru- 
ation, the secretion from the skin is increased ; the urine salts are 
more abundant ; there is a freer elimination of carbonic acid from 
the lungs. The skin acts more freely, and there is often a free ac- 
tion of all the mucous membranes. This shows that the process 
of elimination is more active in every way and compensates for 
menstruation. Indeed, the increased activity in elimination, in some 
cases, appears to be out of proportion to that which is necessary to 
compensate for menstruation. Should these compensating changes 
in the nutritive system fail, the subject is sure to suffer more or less. 

Regarding the management of patients at the menopause, the 
reader should recall the facts stated when discussing the care of girls 
at puberty. The same rules of hygiene which should be observed 
when the menstrual function is being estabhshed, are equally effect- 
ive when that function is being given up. Bearing in mind that the 
sexual organs are preserved in health largely through the agency of 
the nutritive and nervous system, every effort should be made to pre- 
serve good general health at the menopause. All causes which act 
unfavorably upon the nervous system should be guarded against. 

Those who live generously and exercise little, should take less 
food and do more work, while those who are overtaxed and pooily 
fed, should have rest and a better diet. 

Any disease or derangement of the functions of the sexual or- 
gans which may exist when the patient is drawing near to the timo 
for the cessation of the menses, should be attended to. Much harm 
has arisen by physicians advising patients who are suffering from 



THE MENOPAUSE. 425 

symptoms referring to the pelvic organs to have patience, and thej 
will be all right after the change comes. 

The diseases and disorders relating to the " change of life " may 
be classified as follows : 

1. Premature menopause, caused first, by certain conditions of 
the sexual organs, and, second, by diseases of the general system. 

2. Prolonged menstruation, caused first, by local diseases ; sec- 
ondly, by constitutional affections. 

3. Diseases and derangements of the nervous system, due to the 
menopause. 

4. Derangements of the nutritive system, due to the menopause. 

5. Diseases of the sexual organs due to the menopause. 
Typical cases of each of the above-named classes are frequently 

met with, but more often the cases are complicated. Deranged 
digestion and nervous troubles often go together. Some local affec- 
tion and a general disturbance are combined, and in some of the 
worst cases, the whole organization is upset. 

There is also a great variety in the character of the diseases and 
derangements grouped under each head. In the disorders of nutri- 
tion, there are two leading forms of trouble : In the one, the appetite, 
digestion, and assimilation are all defective ; while, in the other, dis- 
integration and elimination are most at fault. 

A similar but far greater variety of affections is presented by the 
nervous system. An almost endless number of diff'ering symptoms 
is encountered here, which tends to confusion ; still, there are two 
principal divisions which may form the basis of a classification, viz., 
those which manifest morbid excitation of the nervous system and 
those which show a depression. 

There is, of course, a marked distinction between those who 
suffer from derangement of the organic nervous system and those 
in whom the cerebro-spinal system is affected. 

ILLUSTEATIVE CASES. 

A Case illustrating the Normal Menopause. — A lady who had a 
very good constitution, and, with the exception of having had some 
acute diseases in early life, had enjoyed uniform good health. She 
had borne five children, and after the birth of the last one she men- 
struated regularly and perfectly. When she was forty-six years 
old, the menstrual flow began to diminish in quantity and duration, 
varying a little in this respect from time to time. In six months 
from the time that the change began, the duration of the How was 
reduced from five days to two. She then missed two periods, and 



426 DISEASES OF WOMEN". 

then the flow returned, and lasted three days, and was a little freer. 
Then she went for four months, when there was a slight show for 
part of a day, and that was the end. 

During the time when the gradual diminution of the flow was 
taking place, she became somewhat languid and indisposed to her 
usual mental and physical activity. Her appetite was not quite as 
good as formerly. While languid when undisturbed, she was easily 
roused by any excitement. Her face would become flushed, her 
hands and feet clammy, and she was nervous and irritable. lYhen 
these feelings passed away, she felt annoyed to think that she could 
not control herself as in times past, and would become a little de- 
spondent. All these symptoms were more pronounced at the men- 
strual periods. When sufl:ering most she felt that if she could have 
a free menstrual flow it would relieve her. These feelings continued 
to annoy her until the flow ceased entirely, and for about nine months 
afterward, but they diminished in severity, and finally left her alto- 
gether. 

After the cessation of the flow, she gained considerable flesh, and 
her former mental and physical activity returned, and her health has 
been excellent ever since. 

When the diminution in the flow began, and her peculiar symp- 
toms came on, she consulted me about her condition. When told 
that all could be attributed to the change of life, she pleasantly ac- 
cepted the situation, and made no change in her mode of life, nor 
did she take any medicine. This enabled me to obtain the history 
of the case unmodified by treatment. 

Premature Menopause caused by Deranged Innervation. — The pa- 
tient was one having a good organization, but a very marked nervous 
temperament. She had three children, the youngest of whom was 
five years of age when I first saw her. She was then thirty-six years 
old. Three years before our first consultation she had many exciting 
cares thrust upon her, which affected her nervous system very injuri- 
ously. Though possessed of means suflScient to secure every luxury 
of life, her cares depressed her greatly, and exhausted her nervous 
system. Her nutrition was impaired to some extent, but still she 
had the appearance of one in fair health, although she was restless, 
sleepless, had headache very often, and suffered from wandering 
neuralgic pains. 

Her sufferings in this way had continued for about one year, 
during which time the menstrual flow was at times scanty and less 
in duration than normal. Then the menses stopped altogether for 
six months, then returned for several months, though scantily, then 



THE MENOPAUSE. 427 

ceased for two months, returned once, and then again in four months, 
and then stopped entirely. 

Five months after the last menstruation was the time that I first 
saw her. She consulted me because she fancied that if her menses 
would return her health would improve. To describe her symptoms 
would be tedious and unprofitable ; suffice it to say that she presented 
typical neurasthenia. There was no organic disease noticeable out- 
side of the nervous system. Being fully satisfied that if the men- 
stmal function could ever be restored, it must be accomplished by 
restoring the nervous system first, the treatment was directed to that 
object. Sleep at night was obtained by giving thirty grains of bro- 
mide of sodium late in the afternoon, and half an ounce of wliisky at 
bed-time. Aconitia, one two-hundredth of a grain, relieved her at- 
tacks of neuralgia. Massage and general faradization were employed 
daily, and tonics were given, consisting, first, of valerianate of zinc, 
then pyrophosphate of iron and arsenic, and then iodide of iron. 

Citrate of iron and quinine was also given at times. The form 
of tonic was changed whenever she became used to that which she 
was taking, and the most appropriate diet was given. Her general 
health improved gradually, and in the summer she was able to rest 
and enjoy life in the country by the sea. Sea-bathing was also tried 
after a time with benefit. About one year of this treatment restored 
her health, but the menses did not return. In fact, the restoration 
of that function v/as despaired of after three months' treatment, when, 
on examination, it was found that the organs of generation had un- 
dergone complete involution. 

Premature Menopause due to Chlorosis. — The following case is 
taken from Tilt's valuable work on " The Change of Life." The 
case is given as " Chlorosis mistaken for Cessation," but, from my 
way of looking at the matter, I think that the chlorosis was the cause 
of the early cessation of the menstrual function. Chlorotic women 
are liable to cease menstruating at an early period, and frequently 
suffer at the change just as they do at puberty. Entertaining, as I 
do, the views given in a previous chapter on chlorosis, it is not pos- 
sible for me to believe that chlorosis could be developed at the meno- 
pause. It is a condition due to imperfect development, not to change 
in structure : 

" Case. — Annie W., aged thirty-three, and married, had an anie- 
mic hue of countenance. The menstrual flow first came at thirteen ; 
had been regular and without pain until twenty-one, when she mar- 
ried, and had one child at twenty-four. There had been a gradual 
diminution of the menstrual flow for the previous year, with intense 



428 DISEASES OF WOMEN. 

debility, epigastric faintness, and drencliing perspirations, and a loud 
Iruit de souffle in the carotids. Was it a case of chlorosis in a mar- 
ried woman or chlorosis occurring at cessation ? I inferred the latter 
from the gradual failing of the menstrual flow, and the pertinacity 
of the flushes and perspirations. A camphor-mixture, a belladonna- 
plaster to the pit of the stomach, and sulphate of iron in pills, cured 
the patient, and when I saw her again, three years afterward, her 
health was good, but there had been no return of the menstrual 
flow." 

The Menopause delayed by Fnngosities of the Endometrium. — This 
patient was married, and the mother of five children. After the 
birth of her last child, she suffered from uterine leucorrhoea, proba- 
bly caused by endometritis. She had fair health in spite of that, 
and menstruated regularly until she was forty-six years old, and then 
the menstrual flow became more profuse. This continued intermit- 
tently for nearly one year, when the menses came more frequently, 
lasted longer, and the flow was quite profuse. Her health failed 
gradually ; she became anaemic, weak, low-spirited, and nervouSo 
Though her flesh remained (she was rather stout), her strength was 
greatly reduced. Her family physician gave her the usual remedies 
— lead and opium, ergot, cannabis Indica, and aromatic sulphuric 
acid — in the hope of controlling the flow, but without effect. 

Finally she consented, with some reluctance, to an examination, 
when a large number of polypoid growths were found in the cavity 
of the uterus. These Avere removed with the curette, and the flow- 
ing stopped for six weeks ; it then returned for a few days, but was 
not YQYy free. There was a return of the menstrual flow in two 
months, very scanty, and another in three months, and that was the 
end of it. She w^as then forty-eight years old. After the removal 
of the fungous growths with the curette, her health improved under 
tonic treatment, and, when last seen, at forty-nine years of age, she 
was quite well. 

Derangement of the Ganglionic Nervous System (from Tilt). — Gan- 
GLioN^ic HrPER^STHESiA. — Miss C. was forty-eight, tall, stout, with 
dark hair, and a flushed face. The menstrual flow came regularly 
from thirteen to forty-seven, then irregularly, being often a mere 
show. This patient had never been nervous or hysterical, and she 
now complains of pain at the pit of the stomach, which first appeared 
when the menstrual flow became irregular, and says that she is never 
without uneasy sensations at the epigastric region, which do not 
generally interfere with her occupations ; but paroxysms of acute 
pain often occur, especially at night, when they suddenly awaken 



THE MENOPAUSE. 429 

her from a sound sleep. The pain then experienced is described as 
a '' tearing pain," and, after it has lasted from ten to twenty minutes, 
ropy mucus comes from the mouth, by expuition, without eructa- 
tions. When the intensity of the pain has abated, the patient lies 
for hours conscious, but prostrate. Sometimes she faints after a bad 
attack ; then she is forced to keep her bed a day or two, and during 
the last six months flushes and perspirations have been abundant. 
The tongue was clean, digestion good, and no trace of tumor at the 
pit of the stomach. I had six ounces of blood taken from the arm, 
and I gave two tablespoonfuls of a comp. camphor mixture before, 
and ten grains of carbonate of soda after meals ; two comp. col. pills 
and ten grains of Dover's powder on alternate nights, and a mustard 
or a Unseed poultice was applied to the pit of the stomach every 
night. The camphorated mixture that I gave in such cases, before 
the bromides came into use, was composed of three drachms of tinct- 
ure of castor, six drachms of tincture of hyoscyamus, and '^ve ounces 
of camphor julep. After continuing all this for a month, the par- 
oxysms came only once a week, instead of almost every night ; I then 
ordered a warm bath to be taken for an hour every night just before 
going to bed ; belladonna and opium plasters to the pit of the stom- 
ach alternately every week, and a scruple of sulphur once a day. 
This was persisted in for six weeks, and was then left off, as there 
had been no paroxysms for ten days. When the patient left town, 
I advised her to take the mixture should she feel worse, as well as 
the pills and the sulphur, and to have six ounces of blood again taken 
from the arm in three or four months. This case seems to me best 
accounted for by admitting a neuralgic affection of the ganglionic 
nervous center ; for the stomach performed all its functions health- 
ily, there was no sign of cerebral disorder, neither was this affection 
obscured by other nervous disorders. It caused no hysteria, no 
pseudo-narcotism, not even headache. The neuralgic character of 
the case was well marked by the paroxysmal outburst of the pain, 
its seat in the central ganglia by the exhaustion that followed the 
attacks. 

The following case from Tilt, illustrates another of the same 
class of affections. 

Ganglionic Dysaesthesia. — Sarah B., tall, stout, and healthy-looking, 
with brown hair and hazel eyes, was forty-seven when she came to 
the Paddington Dispensary, September 8, 1849. The nienstnial 
flow flrst appeared at seventeen, was always regular, and accompa- 
nied by pseudo-narcotism. She married at twenty -Ave, had two 
children, and the menstrual flow left suddenly, without known cause, 



430 DISEASES OF WOMEK 

at forty-four. Since tlien she has been entirely free from lumbo- 
abdominal pains, but has suffered much from other nervous symp- 
toms. There has been no headache, but a heavy, stupid feeling in 
the head, with drowsiness in the day after sleeping well at night, 
and forgetf ulness of familiar things. She was nervous, desponding 
and low-spirited ; often shedding tears, and had strange sensations in 
the throat. Ever since cessation she had been distressed by a flutter- 
ing at the pit of the stomach, " as if something were perpetually 
swinging within her." It becomes worse after meals, generally 
abates when she lies down, is seldom felt when in bed, but begins 
as soon as she rises. When turning the corner of a street, this sen- 
sation makes her feel afraid of losing her center of stability and of 
overbalancing herself ; and when she has it in bed, she feels " as if 
a tub were rolling to and fro within her," and then " the head goes 
too," as "if something rose from the pit of the stomach to the 
head, making it feel giddy and bewildered." Since cessation, she 
has been troubled by burning flushes, without perspirations ; and 
there is sometimes a good deal of pudendal irritation. There was no 
organic disease of the heart, aortic pulsation, or dyspeptic condition 
to explain these singular symptoms ; several practitioners have told 
her " it was all nonsense ; " but it will not do to deny a patient's 
statement because sensations can not be explained. I ordered the 
compound camphor mixture before meals and on going to bed ; car- 
bonate of soda after meals ; a large opium plaster to the pit of the 
stomach ; and a small teaspoonful of sulphur and carbonate of mag- 
nesia over night. September 15th. — She was better ; a lead lotion 
for the pudendal irritation, and ten grains of Dover's powder every 
night. October 6th. — Instead of perspirations, a papular eruption 
has appeared on the shoulders, and she feels rather worse than bet- 
ter ; but the remedies were continued, with the addition of com- 
pound col. pills, to be taken occasionally. October 20th. — All the 
cerebral symptoms have vanished, she is much better, and can bas- 
tle about; but the swinging sensation in the epigastric region still 
remains. The improvement coincided with gentle, well-sustained 
perspirations. I ordered the mixture and soda as before, but dis- 
continued the sulphur and Dover's powders ; prescribing, instead, 
sulphur, two ounces ; borax, one ounce ; Dover's powder, one 
drachm ; two scruples of the j^owder to be taken in a little milk, at 
night. A blister was ordered to the pit of tlie stomach. I^ovem- 
ber 6th. — She looks cool and comfortable, is much stronger, and is 
less troubled by the swinging sensation. The blister did no good, 
so I ordered a rotation of belladonna and opium plasters, each to be 



THE MENOPAUSE. 431 

worn a week on the epigastric region, and the mixture and com- 
pound sulphur powders to be continued. J^ovember 23d. — The 
patient was discharged cured. 

ExcrementitioTis Plethora, Oppression, and Derangement of the 
Nervous System from the Menopause. — A strong-looking German 
lady gave me the following history : She w^as married and in quite 
comfortable circumstances. She had six childreu, the youngest be- 
ing eleven years old. From the time of her last confinement her 
health has been good and she menstruated normally, until she was 
over forty-six years of age. Her menses came then at the proper 
time but lasted two weeks and the flow was too free. After a lapse 
of three months the menses came again in a diminished degree, and 
again in two months, scantily. From the time of her free menstru- 
ation, when she was about forty-six years old, her health failed grad- 
ually. She had always been a generous liver, and continued to take 
her nourishment well, but she became languid, indisposed to exer- 
tion of any kind, had headaches, was drowsy and sleepy all the time, 
but often had restless nights. Her mind was disturbed so that she 
was depressed in spirits, quite fretful, did and said " queer things " 
which alarmed her family, and her memory was less reliable than 
formerly. She had little interest in her former duties and amuse- 
ments, but occupied her time mostly in thinking and talking about 
her feelings. There were flushings of the face at times, which she 
described as rushing of blood to the head, which she fancied might 
kill her. There were profuse but brief paroxysms of perspiration, 
which came at times without any phj^sical exertion. She was quite 
fleshy, and excepting an anxious expression of the face, had the ap- 
pearance of good health. The tongue was coated, the bowels con- 
stipated, the urine was loaded with phosphates ; the pulse full but 
slow, and at times irregular; the appetite was not good, but she 
took food in abundance and drank wine and beer in the hope of 
getting strength. She suffered from labored digestion and flatulence 
and a sense of fullness in the region of the stomach. The sexual 
organs had undergone complete involution although the vagina was 
relaxed and showed some venous congestion. 

The treatment was first, ten grains of blue-mass, three grains of 
calomel, and one grain of ipecac, given at bed-time, followed in the 
morning with a dose of sulphate of magnesia. This was repeated 
twice, at intervals of five days, and after that, the following mixture 
was given : Bromide of sodium, half an ounce; salicylate of sodium, 
two drachms ; wine of colchicum-seeds, two drachms ; sirup and 
water enough to make three ounces, and a teaspoonful to be taken 



432 DISEASES OF WOMEN. 

before meals. She improved very much, on this treatment, and the 
mixture was continued for about six weeks. After the effects of 
the mercurial cathartic had passed oif, she became constipated, and 
the following pill was given at bed-time. Sulphate of quinine, one 
grain ; extract of belladonna, one eighth of a grain ; and rhubarb, 
two grains. When this was not sufficient to move the bowels 
freely, a glass of Congress water was given an hour before breakfast. 
Wine and beer were gradually given up, and her diet simplified and 
reduced in quantity. Exercise in the open air was prescribed, and 
light, agreeable mental occupation. The progress of the case was 
quite satisfactory for about two months, then there was a standstill 
for a time. The medicine was then changed to a mixture of hydro- 
chloric acid, one and one half drachm ; tr. nux vomica, one and one 
half drachm ; tincture of cannabis Indica, two drachms ; tincture of 
card anion, one ounce ; and simple sirup, two ounces'; one drachm 
before meals in water. The pill at bed-time was continued. This 
last prescription was given for about two months with an interval of 
three days after each bottle, when she took the pill only, at night. 
From this time onward, the progress of the case was steady until 
she finally recovered her former good health. 

Such a case as this is infrequently seen in practice. The causes 
being conditions of life favoring derangement of nutrition and 
sluggish disintegration, aggravated greatly by the rather abrupt ces- 
sation of the menses. 

Impaired Digestion and Assimilation arising from the Cessation of 
Menstruation. — This lady was married and the mother of a family, 
of spare habit and a nervous temperament, but her health had been 
good in the past. When she was forty years of age, her menstrual 
How diminished in quantity and duration, and simultaneously her 
appetite failed, and she lost flesh and strength. 

Always an active person, she now became restless, nervous, and 
irritable. Her tongue was clean, but of a deeper color than normal, 
showing that rapid exfohation of the epithelium was going on. The 
bowels were constipated, the urine was abundant and of light color 
usually. Her skin was slightly bronzed and usually dry, although 
she had occasional outbursts of free perspiration. Her pulse was 
weak, and at times irregular. Her head ached quite often and she 
had wandering pains about the chest and abdomen. Her greatest 
trouble was a feeling of distress in the stomach after eating. Eight 
months from the time that the menstrual flow began to decline, it 
stopped altogether, and two months afterward I first saw her. 

As the physical condition of this patient was ahnost exactly the 



THE MENOPAUSE. 433 

opposite of the preceding case, the treatment was necessarily very 
different. She was directed to take nutritious food in small quan- 
tity, six times a day ; to rest as much as possible and have massage 
at night, which gave better sleep. 

At first, she was given five grains of oxalate of cerium, half an 
hour before meals, and a teaspoonful after meals, in warm water, 
of a mixture of lactic acid, tincture of columbo, and pepsin wine, 
and she improved so far as to take food, and digest it with less 
trouble, but her strength did not return as fast as I desired. She 
was also constipated. A tonic laxative pill was then given before 
meals consisting of quinine, belladonna, and compound extract of 
colocynth ; and after meals, she was given a teaspoonful of whis- 
ky with four drops of tincture of nux vomica and four grains of 
animal charcoal. This appeared to help her, and this course of 
tonic treatment was continued very faithfully for three months, 
when she considered herself sufficiently well without further treat- 
ment. 

Two years afterward she was found to be in good health. 

Circumscribed Inflammation of the Vagina and Cervix Uteri, partly 
due to the Menopause. — The patient was first seen when she was 
forty-eight years old. The menses had stopped one year and two 
months before. Her health was fairly good and always had been, 
but for some time before the menopause and all the time after, she 
had been distressed by a discharge from the vagina of sero-purulent 
but rather tenacious material, which caused some external irritation. 
There was heat and burning in the pelvis which became more 
marked on walking. She had put up with her troubles so long, be- 
lieving that it was due to change of life and would pass off in time. 
In fact, she had been told this by her physician. But, instead of 
disappearing, she found that the trouble increased, if indeed it 
changed at all. Her general health was below par considerably, 
but there was no organic disease of the organs of nutrition, and yet 
ultimate nutrition was a little sluggish. 

The sexual organs had undergone final involution ; the uterus 
was small, but the os externum was open, and coming from the 
canal was a tenacious, darkish-colored discharge, not unlike the leu- 
corrhoea found in young subjects and heretofore described under the 
head of " Cervical Endometritis in the Imperfectly Developed 
Uterus." 

The mucous membrane about the exteraal os was eroded in 
patches, and on the anterior lip of the cervix there were some granu- 
lar spots that looked as if they were the products of epithelial hy- 
29 



434: DISEASES OF WOME!^. 

perplasia. The appearance of the vagiDa was peculiar. In place of 
the general congestion of a well-marked vaginitis, the mncons mem- 
brane was studded with small red points or patches, while the inter- 
vening portions of the membrane were pale. The surface of the 
membrane was covered with a sero-purulent discharge ; at the vulva 
there were several patches of congestion larger than those higher up 
in the vagina. Some of these were of a deep-red and slightly blu- 
ish color. 

The thought came to me that this might be malignant disease of 
the cervix just beginning, but this was put aside, because of the 
duration of the trouble and the fact that I have several times seen 
this condition after the menopause. 

I have also frequently seen the same conditions in young insane 
women who had amenorrhoea. These facts led me to suppose that 
the inflammatory action was due to impaired nutrition which is pres- 
ent at the involution of the sexual organs. This low grade of in- 
flammatory action is no doubt more likely to occur in those who 
have had some ordinary cervical endometritis and vaginitis before 
the menopause. The circumscribed red spots, looked to me hke a 
few live coals here and there in the ashes left after the fires of 
functional life and inflammation had subsided. 

The treatment consisted of general tonics and local astringents, 
citrate of iron and quinine was given internally, and a teaspoonf ul 
of sulphate of zinc in a quart of water for a vaginal douche. 

The parts about the os externum were touched once with a fifty- 
per-cent solution of chloride of zinc. The sulphate-of-zinc injec- 
tions did very well for a time, but the progress was favored by an 
occasional application of glycerin and tannic acid. 

The local improvement did not surpass the general regaining of 
strength, but kept pace with it. The recovery was permanent and 
perfect. 

Pelvic pains of a neuralgic character are common about the 
change of life, and are often due to it. The following two cases 
from Tilt will illustrate this form of trouble. 

Ovario-TJterine Neuralgia. — Miss X., was forty-seven when she 
first consulted me. She is small, but well-proportioned ; has been 
highly nervous all her life. Menstruation was irregular, and there 
was a muco-purulent discharge, vaginitis, and decided ulceration of 
the cervix, and a most irksome sensation of heat and irritation in the 
passage. I cured the vaginitis and ulceration by surgical measures, 
without rehevin^ the vaginal heat and pruritus, so I sent the patient 
out of town. When she returned, after many months, the pruritus 



THE MENOPAUSE. 435 

was as bad as ever, and would come on after any excitement or 
fatigue, or standing about, and would be relieved by resting with the 
feet higher than the pelvis. This vulvo-vaginal irritation w^ould 
sometimes disappear on the coming on of a similar pruritus on the 
palms of the hands and on the soles of the feet, showing that how- 
ever much the chief seat of neuralgia might be in the womb or va- 
gina, the ultimate nervous expansions in other parts of the body 
might similarly suffer. When this irritation affects the feet and 
hands there is nothing to be seen there, and she refrains from scratch- 
ing them because it would prolong the irritation for hours. As 
might have been predicted, the symptoms were worse at night, and 
led to great exhaustion and despondency. I have watched this state 
of things for twenty years, and at times could give no relief. She 
was always better for plenty of food and wdne, and for such small 
quantities of citrate of iron and quinia as she could bear. I tried 
all sorts of injections ; tar- water did most good, but it has been re- 
peatedly advisable to leave off all kinds of injection, for they seemed 
to do naore harm than good. I syringed the vagina with a solution 
of nitrate of silver and touched the passage with the solid caustic, 
with questionable benefit. A rectal suppository, containing a grain 
of opium and one of extract of belladonna often gave temporary re- 
lief, but this remedy could not be relied on. By the sacrifice of her 
own health many a daughter has well repaid the gift of life ; and 
when my patient lost her mother, who had been long a cripple, re- 
quiring anxious and fatiguing nursing, she went out of town and got 
fat, and now suffers much less, only having a slight return of the 
old symptoms when she gets weaker and more nervous. 

Ovario-XTterine Neuralgia. — A very strongly-constituted lady, aged 
forty-seven, is said to have had some acute uterine disease twenty 
years ago, while residing in France, when forty leeches were ap- 
plied above the pubis. With the exception of not being able to re- 
tain the urine so well as previously to this attack, health remained 
so good that every year she was able to take long pedestrian excur- 
sions with her husband. She never conceived, and menstruation 
ceased suddenly at forty- four ; in the following months the nose bled 
very frequently, and the bowels became constipated ; for which she 
went to Homburg and w^as restored to health. On returning to 
town, in December, 1868, she took very cold enemata, for constipa- 
tion, which was so great that a wineglass of Friedrichshall water, 
taken every hour, failed to produce watery motions, and only irri- 
tated the bladder, apparently causing the strange abdominal sensa- 
tions which have lasted ever since. The patient feels as if there were 



436 DISEASES OF WOMEK 

a heavy body in the pelvis, bearing down upon the rectum, with a 
burning sensation, referred sometimes to that organ, sometimes to 
the vagina, or to the bladder. When in bed and lying down, with 
the feet up, she feels comfortable ; by the time she has half done 
dressing the burning sensation begins, and lasts until the bowels 
have been moved ; soon after this the burning comes back ; it is ag- 
gravated by standing or sitting, by indigestion, flatulence, constipa- 
tion, and repletion of the bladder ; also by worry and bad news. 
The sensation is reheved by moderate walking, by lying down, and 
by regularity of the bowels. Komburg was again tried ; it did 
good, but on her return the lady was as bad as before, and consulted 
several doctors. One attributed the sufferings to stricture of the 
rectum, another to irritation of the bladder, a third to displacement 
of the womb. The following summer Homburg was tried for a 
third time, but the waters were soon left off, for they aggravated all 
the symptoms, and after the patient's return to town Dr. Beale sent 
her to me. In addition to the pelvic symptoms already described a 
strong-minded, sharp, matter-of-fact woman was in a state of mental 
confusion ; her brain felt muddled, and she would sit for hours doz- 
ing or doing nothing ; despondency being doubtless increased by 
finding herself helpless as a child, after having passed all her life in 
doing everybody else's business as well as her own. She forgot 
where she put things ; once thought she had taken out a large sum 
of money in her purse, and that she had lost it, whereas a month 
afterward she found it in some out-of-the-way place. On examin- 
ing, I found the rectum perfectly healthy, notwithstanding the pain 
and stricture ascribed to it. I was given to understand that marriage 
had never been concluded, and the vagina was so narrow that I could 
with difficulty introduce part of my index-finger; so I ordered lin- 
seed tea and laudanum injections, three times a day, and henbane 
internally. A few days afterward I was able to reach the os uteri ; 
I found the womb exquisitely sensitive ; and on sounding the blad- 
der there was nothing abnormal, except great pain when the sound 
passed over the urethra, the pain not being caused by inflammation, 
for the finger in the vagina did not feel the urethra as a hard and 
round body painful on being pressed. Injections with acetate of 
lead and laudanum, as well as opium and belladonna rectal supposi- 
tories, enabled me, a little later, to examine the womb without giv- 
ing pain ; there was no ulceration and there had been little vaginal 
discharge. The pain was most felt at the opening of the vagina, 
Avhich looked sore, red. and injected, a condition that accounted for 
a verv unusual hardness of the recto- vaginal tissues, a hardness of 



THE MENOPAUSE. 437 

which the patient was sensible, and complained of as something 
wrong witli " the bridge." This was caused by long-continued con- 
gestion, although the parts were then without heat or redness. This 
sore state of the vaginal opening was relieved by the application 
twice a day, of zinc-ointment, to each ounce of which was added a 
drachm of diluted hydrocyanic acid. Yaginitis becoming worse, I 
swabbed the vagina once a week with a solution of nitrate of silver, 
and I ordered alum and zinc injections ; suppositories did harm, 
whether administered by the vagina or the rectum. After thus 
treating the patient for a few months, the sensations of burning and 
weight had considerably diminished, but were often troublesome. 
Digestion was much improved by nitro-muriatic acid and pepsin ; 
pseudo-narcotism and mental disturbance were not relieved by bro- 
mide of potassium, but were much reduced by henbane and Indian 
hemp; and then the patient took, for two months, three times a 
day, at meals, the twenty-fourth of a grain of arseniate of iron, 
made into a pill with a fourth of a grain of Indian hemp — a combi- 
nation suitable alike to the general nervous derangement and to the 
abdominal neuralgia. This leads me to the question of diagnosis. 
*rhere was no organic disease of the bladder or rectum, nor of the 
womb, neither displacement nor ulceration of this organ. The dis- 
ease originated in vaginitis, kept up by excessive walking and drastic 
medicines, at the change of Hfe. The vaginitis causing neuralgia of 
both the sensory and the ganglionic pelvic nerves, the neuralgia 
causing pseudo-narcotism and the other forms of cerebral disturb- 
ance that usually attend the menopause ; the neuralgic element of 
the case being shown by the patient's often feeling the disturbance 
to ascend, as it were, from the pelvis along the spinal column to the 
back part of the head, where there was most suffering. There was 
a gradual recovery of health, and this patient has been able to re- 
sume her usual very active life. 

A long list of diseases has been given as occurring at the meno- 
pause. This list covers nearly all the ills that flesh is heir to. The 
majority of these have no relations to the menopause excepting that 
when there is a predisposition to any disease, the disturbances of the 
system due to the change, would favor the outbreak at that time. 

ISTo notice need be taken of those affections which are common 
to all periods of life, the menopause only determining the time of 
their development. When there exists a predisposition to any of 
the constitutional diseases, the condition of nutrition at the meno- 
pause, and the disturbed or unbalanced state of the nervous system, 
favor the outbreak of these morbid tendencies. 



CHAPTER XXIY. 



DISEASES OF THE OVAKIES. 



THE ANATOMY AND PHYSIOLOGY OF THE OVARY. 

The ovaries are two bodies, in shape somewhat like an almond, 
situated in the pelvic cavity, one on either side of the uterus, and 
removed from it about one inch. They are connected with that 
organ by the Fallopian tubes and the ovarian ligaments. Before 
birth the ovaries are on a level with the iliac fossa, and it is not until 
the tenth year of life that they reach what may be considered their 
permanent position — that is, the lateral and posterior part of the 
true pelvis. Hasse, of Breslau, in a female cadaver frozen in the 
upright position found that the long axis of both ovaries ran out- 
ward and forward, form- 
ing with the transverse 
axis of the uterus an an- 
gle open to the front, 
with one half of the or- 
gan projecting above the 
plane of the pelvic brim. 
Schultze, on the contrary, 
regards the long axis of 
the ovaries as being in 
an antero-posterior posi- 
tion, as shown in Fig. 
185. It must be borne 
in mind, however, that 
the position of the ovaries is not a fixed one ; their relation to the 
uterus and the other pelvic organs is such that, when any one of 
these is displaced, a change in the position of the ovaries will of 
necessity occur ; thus the full or empty bladder or rectum acting 
upon the uterus will tend to push the ovaries in one direction or 
another. 




Fig. 185. — The fundus uteri and ovaries seen through 
the pelvic brim (His). The cross is in the center 
of the pelvis and on the fundus ; o, o, ovaries 
encircled by the Fallopian tubes in their backward 
sweep. 



DISEASES OF THE OVARIES. 439 

The average dimensions of each ovary are : Length, one inch and 
a quarter ; width, three quarters of an inch ; and thickness, half an 
inch. Its weight is about eighty grains. As its position changes, 
so do also the measurements here given. It is probably in its most 
perfect condition in the virgin at about the age of puberty. Ac- 
cording to Hennig's observations, the ovary increases in length dur- 
ing pregnancy, but neither its breadth nor thickness exceeds that 
found in the virgin. When pregnancy has ceased, the ovaries become 
smaller, and do not at any time subsequently regain the dnnensions 
possessed by the virgin ovary. 

The relation of the ovaries to the broad ligament is a matter of 
great importance and interest. These ligaments consist of two folds 
or layers of the peritonaeum, with a lining of muscular tissue, be- 
tween which lie the uterus and its appendages. The ovaries, how- 
ever, are not situated between these two layers, but are suspended, 
so to speak, from the posterior surface of the posterior layer, and 
are, therefore, entirely behind both layers or folds of peritonaeum, 
which form the broad ligament, but attached to the posterior layer 
by their long axis, this attached portion of the ovary being termed 
the hilum. In the anterior face of the posterior layer of the broad 
ligament, on either side, is an opening or slit through which the 
blood-vessels, nerves, and lymphatics of the ovary pass. The ovarian 
ligaments which connect the body of the uterus and the ovaries, 
leaving the former at a point between the Fallopian tubes and the 
round ligaments, after running for some distance between the two 
layers of the broad ligament, pass out by these openings in the pos- 
terior layers to the ovaries. These ovarian ligaments are about one 
inch in length, and are composed of fibrous tissue, into which some 
of the uterine muscular tissue is prolonged (Fig. 18G). Each ovary 
is also connected with the corresponding Fallopian tube by one of 
its fimbriae, and through this to the pelvis by means of the infundib- 
ulo-pelvic ligament — a ligament about two thirds of an inch in 
length, running from the outer end of the Fallopian tube to the wall 
of the pelvis. Thus the ovary is maintained in its position — subject, 
however, to considerable alteration — by the broad, the ovarian, and 
the infundibulo-pelvic ligaments. 

The supply of blood to the ovaries is by the ovarian artery, a 
branch of the abdominal aorta, corresponding to the spermatic artery 
of the male. 

After this artery enters the pelvis, it passes between the layers 
of the broad ligament in a direction toward the upper angle of the 
uterus ; its course is parallel to, though below, the Fallopian tube. 



440 



DISEASES OF WOMEN. 



It sends branches to the ovary, which pass out from between the 
layers of the broad ligament to the ovary through the opening in 




Fig. 186. — The ovary and its ligaments (Henle). Ui, uterus; Od, Fallopian tube ; 
lo, ovarian ligament ; i/>, infundibulo-pelvic ligament ; zo, infundibulo-ovarian liga- 
ment ; Fo, fimbria ovavica ; Po, parovarium. 

the posterior layer already referred to. Other branches supply the 
Fallopian tube and anastomose with the uterine artery. The venous 
blood of the ovary passes into the ovarian plexus, sometimes spoken 
of as the pampiniform plexus, which is situated between the layers 
of the broad ligament, and is thence carried to the inferior vena cava 
on the right side, and to the renal vein on the left. These veins, 
which form a network in the ovary, have, according to Rouget, as- 
sociated with them muscular trabeculse, which, in their contraction, 
prevent the passage of the blood from the ovary into the large venous 
trunks, and thus permit of what may be termed an erection of the 
ovary. It is probable that during the act of coition such a condition 
takes place in the ovary, increasing its size to a considerable extent, 
and causing it to become firmer and more sensitive. Rouget de- 
scribes the lymphatics of the ovary as united into six or eight trunks, 
which accompany the ovarian artery, and discharge into the middle 
and superior lumbar lymphatic ganglia. The lymphatic circulation 
becomes of special importance in explaning the method by which, 
under certain conditions, septic matter is absorbed, producing sep- 
ticaemia. The ovarian and uterine plexuses communicate, as do the 
arteries of the same names. 



DISEASES OF THE OVARIES. 



441 



The nerves of the ovaries, as v^ell as those of the uterus, arise 
from the coeliac plexus, which is in part distributed to the ovaries 




uterine and vaginal arteries (Hyrtl). 



and to the spermatic ganglia. According to Frankenhauser, the 
superior mesenteric plexus supplies these spermatic ganglia, whicli 
Courtj suggests would be better called genital ganglia. These gan- 
glia, four in number, are supplied from the sympathetic through two 



442 DISEASES OF WOMEN". 

large brandies, and in turn supply the ovaries through a considerable 
number of branches. 

Development of the Ovary. — At a very early period in the devel- 
opment of the foetus, two bodies are formed in the abdominal cavity, 
one on each side of the spinal column ; these are the Wolffian bodies, 
the function of which is undoubtedly similar to that of the adult 
kidney. According to Coste, they are fully formed at the end of 
the first month, and, according to Longet, are hardly visible after 
the second month. While these organs are in a state of activity, 
the kidneys are formed behind them, and at the same time two other 
organs appear in front of the Wolffian bodies, and on their inner 
side ; these are the internal organs of generation — the testicles in the 
male and the ovaries in the female. The detailed history of the 
development of these organs is as follows : At a very early stage of 
development — in the chick as early as the third day — the cells of 
the mesoblast form a longitudinal cord in the mesoblast, one on each 
side of the body, and just external to the pro to vertebrae, which are 
also formed from this same layer. These cords are at first solid, but 
a cavity gradually forms within them, and they become the Wolffian 
ducts. From this primitive tube diverticula are given off, forming, 
as it were, blind tubes, into which blood-vessels enter, and with the 
diverticula form the Wolffian bodies, one upon either side. Another 
portion of the mesoblast projecting in the form of a ridge, and cov- 
ered with '' germ epithelium " on the inner side of the Wolffian body 
— that is, tow^ard the median line — becomes the testicle or the ovary, 
according as the individual is to be of the male or female sex. On 
the outer wall of the Wolffian body an involution takes place from 
the pleuro-peritoneal cavity, forming at first a furrow, but later, by 
the union of its edges, a duct, which is known as Miiller's duct. In 
the female these ducts form the Fallopian tubes, the uterus, and the 
vagina, while in the male they have no special function, although 
the upper part remains as the hydatid of Morgagni, and the lower 
as the prostatic pouch, the uterus masculinus, or sinus pocularis. 
While the Wolffian ducts in the male form the body and globus 
minor of the epididymis, the vas deferens, and the ejaculatorj^ duct, 
in the female the lower part only remains to form the duct of Gaert- 
ner. If the broad ligament is examined with transmitted light, a 
cone, nearly an inch in breadth, of whitish, more or less convoluted 
tubes are seen, in number about twenty, each of which is lined 
with ciliated epithelium, and contains a clear fluid (see Fig. 188). 
This is the parovarium of Kobelt, or the organ of Hosenmiiller, 
and is the remnant of the Wolffian body of fetal life. The path- 



DISEASES OF THE OVARIES. 



443 



ological degeneration of these tubes produces the parovarian cystic 
tumor. 

Minute Anatomy of the Ovary. — The fact that the ovarj is situ- 
ated behind both layers of the broad ligament, and attached only at 




Fig. 188. — Section of the ovary of a bitch (Waldeyer). a, germ epithelium ; c?, ovum ; 
i, membrana granulosa ; /, vitelline membrane, vitellus, germinal vesicle, and spot. 

the hilum, has already been referred to. From this it follows that 
the posterior surface of the ovary is not covered by peritonaeum. 
The more thorough and skillful investigations of recent years have 
satisfactorily demonstrated that the surface of the ovary is in appear- 
ance and structure very different from the peritonaeum. AVhile the 
epithelium which covers the broad ligament is transparent and flat- 
tened, that which forms the surface of the ovary is granular in ap- 
pearance and columnar in form. This marked difference has sug- 



4:4:4: DISEASES OF WOMEN". 

gested to some that the covering of the ovarj was a mucous rather 
than a serous membrane. These cohimnar cells are very similar to 
those lining the Fallopian tubes, except that the cilia which are 
present in the latter are wanting in the former. It is an error to 
regard these superhcial cells of the ovary, which are arranged in a 
single layer, as in any sense a covering of the ovary. They are in 
reality an integral part of the ovary, and, as the name " germ epi- 
thelium" implies, their function is a most important one, being 
none less than the formation of the ova by a modification of their 
structure, as has been so well described by Waldeyer. 

Beneath this layer of germ epithelium is the tunica albuginea. 
This is made np of bundles of spindle-shaped cells, arranged, accord- 
ing to Henle, in three layers, the onter and inner ones being longi- 
tudinal, and the middle one circular. The albnginea contains no 
Graafian follicles. The third layer — that is, the one next to the 
albuginea — is what Schron has described as the cortical layer. This 
contains the smallest of the Graafian follicles arranged in groups, 
but separated by the stroma of the ovary, this latter being made up 
of bundles of spindle-shaped cells, some short and others long, each 
having an oval nucleus, and being probably young connective-tissue 
cells. The Graafian follicles of the cortical layer are spherical or 
slightly oval bodies, with a diameter of one one thousandth of an inch, 
and have as their external poi'tion a delicate membrane — the mem- 
brana propria. Lining this is the membrana granulosa, a layer of 
flat, transparent, epithelial cells, with oval nuclei. "Within this, and 
occupying the entire cavity of the folHcle, is a spherical cell — the 
ovum. The ovum is a collection of granular protoplasm containing 
a spherical or oval nucleus, the germinal vesicle, and this, in turn, a 
body known as the germinal spot. Below this cortical layer, im- 
bedded in the stroma, are Graafian f olHcles of almost every conceiva- 
ble size. While the older anatomists thought the total number of 
follicles in an ovary did not exceed twenty, this number being all 
that could be seen by the unaided eye, some of the more recent 
authorities have placed the number at six hundred thousand. As 
follicles rupture and discharge each month for a long series of years, 
the estimate of the earlier writers is undoubtedly too low — probably 
as much too low as that of some of the recent ones is too high. All 
the layers thus far described constitute the parenchyma of the ovary. 
Between this and the hilum is the vascular zone, which contains no 
follicles, but is made up of bundles of connective tissue and bundles 
of non-striped muscular tissue, which are directly continuous with 
the corresponding tissues of the broad ligament. It is in this vas- 



DISEASES OF THE OVARIES. 445 

cular zone that the blood-vessels of the ovary are found, and, indeed, 
give to it the name which characterizes it. 

The Graafian follicle of medium size is, like that of the cortical 
layer, made up of a membrana propria and a membrana granulosa, 
and contains an ovum. The ovum is, however, larger than that of 
the cortical follicles, and is limited by a thin membrane, the zona 
pellucida or vitelline membrane. This is believed to be formed by 
the cells of the membrana granulosa. As the follicle increases in 
size the ovum does not increase correspondingly, so that, while for 
a considerable time it completely filled the cavity, now it does not 
do so, and the space between it and the membrana granulosa contains 
an albuminous fiuid — the liquor foUiculi. It should be stated that 
a Graafian follicle, while it usually contains but one ovum, does some- 
times contain two or even three ova. At one part of the membrana 
granulosa the cells are more abundant than elsewhere, forming a 
mound which is known as the discus or cumulus proligerus ; in the 
center of this accumulation of cells the ovum is imbedded. Some of 
the Graafian follicles reach maturity, so far as can be told from their 
size and appearance, and undergo degeneration before the age of 
puberty is attained. Some of the small follicles also degenerate, 
never reaching maturity. The number of follicles which thus de- 
generate is by no means inconsiderable, and a knowledge of this fact, 
and that at each menstrual epoch a follicle ruptures, leads us to be- 
lieve that the total number of follicles in an ovary must be reckoned 
by thousands. 

Development of the Graafian Follicles and Ova. — Having described 
the minute anatomy of the ovary, we are now prepared to consider 
the manner in which the follicles and their contained ova are formed. 
The germ epithelium, which forms the superficial layer of the fetal 
ovary, undergoes rapid multiplication, as a result of which the cells 
grow in a direction toward the vascular stroma of the ovary ; this 
likewise increases, and in a direction toward the germ epithelium. 
The stroma, developing between these masses of cells, which are off- 
shoots from the germ epithelium, thus isolates them, forming islands 
or nests. These nests are larger below than above where they are 
for a considerable time still connected with the superficial germ epi- 
thelium. Indeed, at birth this connection exists and forms what 
Pfliiger has denominated the ovarial tubes. The cells composing 
these nests multiply themselves by the process of karyoldnesis, thus 
increasing the size of the nests, and forming new ones by being con- 
stricted off from the old ones. Some of the cells of the genn epi- 
thelium undergo special development in the cell-body and nucleus. 



4:4:6 DISEASES OF WOMEN. 

and become ova, which are spoken of as primitive ova. The germi- 
nal vesicle is formed before the vitellus or the zona pellucida ; but 
whether the formation of the germinal spot precedes that of the 
germinal vesicle has not been fullj decided in the vertebrates. 
Kolhker finds this to be the order in the development of the ova of 
intestinal worms. As the multiplication of the cells of the germ 
epithelium goes on as already described, there is also a continually 
increasing differentiation of these cells forming the primitive ova. 
This production of ova takes place in the nests as well as in the 
superficial layer, and, as a result, we have each nest containing a 
number of ova, and ova are also found in the same manner in the 
ovarian tubes. The membrana granulosa is formed of the cells of 
the nests and tubes which do not take part in the formation of the 
ova. If a nest or an ovarial tube contains several ova, each ovum 
will form a center, around which will be aggregated a layer of cells, 
forming a membrana granulosa, and by the ingrowth of the stroma 
between these collections the Graafian follicles are formed. External 
to the membrana granulosa is formed the membrana propria, and 
still more externally the fibrous capsule or theca f olliculi. As already 
stated, two or even three ova may become enveloped in a single 
layer of cells, and thus a single Graafian follicle be formed contain- 
ing two or three ova. The ova and the membrana granulosa are 
consequently formed from the germ epithelium, which, as has been 
seen, consist of cells from the mesoblast. The membrana propria, 
the theca folliculi, the stroma, and the vessels are produced from the 
fetal stroma, which was also originally an outgrowth of the meso- 
blast. Some excellent authorities, among whom may be mentioned 
Pfliiger and Kolliker, believe that Graafian follicles and ova are pro- 
duced after birth ; others equally reliable, as Bischoff and Waldeyer, 
deny this. 

Ovulation. — The function of the ovaries is primary in the process 
of reproduction. Their physiological activity precedes the uterine 
functions, and continues, as a rule, until the menopause, and possibly 
after it. Hence the functions of the other sexual organs appear to 
be responsive to the influence of the ovaries. 

There are, however, differences of opinion concerning this matter. 
Observations have been made which show that ovulation and men- 
struation occur independently of each other, in exceptional cases at 
least, and a high degree of importance has been given to that aj^par- 
ently independent action ; but such irregularities are the exception, 
not the rule. There are facts in abundance to prove that, when the 
ovaries are absent or rudimentary from birth, the function of the 



DISEASES OF THE OVARIES. 447 

uterus is never established, and the removal of tlie ovaries after 
puberty arrests menstruation in the majority of cases. All that we 
know regarding the influence of the ovaries upon development of 
the individual, and the exercise of the sexual functions throughout 
the reproductive period of life, points to the conclusion that these 
organs are the prime movers and controlling agencies, to speak fig- 
uratively, in the sexual system. The simple facts that ovulation and 
menstruation do not follow each other in consecutive order in excep- 
tional cases, and that the two functions are occasionally performed 
independently of each other, do not affect the general rule in physi- 
ology. Because irregularities occur in the harmonious action of the 
sexual organs, their independence need not be doubted. The same 
natural order of phenomena is observed in all processes of the human 
economy. The primary action of an organ that stands at the head 
of a system sets all the subordinate organs in functional motion. 
Taking food is the first step in the great process of nutrition, and 
digestion and assimilation follow in natural physiological order. 
There are occasional irregularities in the succession of the processes 
of nutrition, as when gastric juice is secreted in the absence of food 
in the stomach ; but such events are exceptions to the rule. Certain 
impressions made upon the brain are followed by definite mental 
phenomena, but the brain sometimes fails to respond to impres- 
sions ; and, again, it occasionally acts independently of extrinsic 
excitants. So, also, an action or function . which has been be- 
gun by a given influence may continue after the cause which pro- 
duced it has been removed. If we accept the idea that the ovaries 
are essential to the very existence of the sexual system, and that their 
ofiice is the highest and the first in the order of events which col- 
lectively make the complete process of production, it is easy to under- 
stand that their absence would arrest the action of the whole system. 
They are paramount, not subordinate, in reproduction, and in the 
maintenance of the relationship between the general and the sexual 
systems the ovaries are undoubtedly the most potential agents. The 
uterus and vagina are superadded structures, rendered necessary by 
a more complex and perfect sj^stem of reproduction in the higher 
species. The anatomical and physiological value of the ovaries as 
factors in the reproductive system suggests an equal distinction in 
their association with the general system, and in their influence upon 
it. This correlation has been variously estimated by authors. 

Dr. Henry Maudsley, in his book entitled " Body and Mind," 
says : " The organic system has most certainly an essential part in 
the constitution and the functions of the mind. In the great mental 



448 DISEASES OF WOMEN. 

revolution, caused bj the development of the sexual system at pu- 
berty, we have the most striking example of the intimate and essential 
sympathy between the brain as a mental organ and other organs of 
the body. The change of character at this period is not by any 
means limited to the appearance of the sexual feelings and their 
sympathetic ideas, but, when traced to its ultimate reach, will be 
found to extend to the highest feelings of mankind, social, moral, 
and even religious. In its lowest sphere, as a mere animal instinct, 
it is clear that the sexual appetite forces the most selfish person out 
of the little circle of self-feeling into a wider feeling of family 
sympathy and a rudimentary moral feeling. The consequence is 
that, when an individual is sexually mutilated at an early age, he is 
emasculated morally as well as physically. It has been affirmed by 
some philosophers that there is no essential difference between the 
mind of a woman and that of a man ; and that, if a girl were sub- 
jected to the same education as a boy, she would resemble him in 
tastes, feelings, pursuits, and powers. To my mind, it would not 
be one whit more absurd to affirm that the antlers of the stag, the 
human beard, and the cock's comb are the effects of education, or 
that, by putting a girl to the same education as a boy, the female 
generative organs might be transformed into male organs. The 
physical and mental differences between the sexes intimate them- 
selves very early in life, and declare themselves most distinctly at 
puberty ; they are connected with the influence of the organs of 
generation." 

This much being claimed by so high an authority for the influ- 
ence of the sexual organs upon the development and function of the 
brain and nervous system, I may inquire how far the ovaries are re- 
sponsible for such results. Yirchow and others have stated that the 
ovaries give to woman all her characteristics of body and mind, and 
I accept the proposition without qualification, feeling sustained in 
doing so by the fact that, when the ovaries are absent or defective 
from birth, the characteristics of the female sex are never fully de- 
veloped. The tendency in the development of those in whom the 
ovaries are congenitally absent is toward the masculine type of the 
race, I have seen two such cases, decidedly masculine in their phys- 
ical and mental attributes, and there are many others recorded in 
our literature. There are some authors, however, who appear to 
stand in opposition to what is here claimed. In Dr. Goodell's paper 
presented to the Pennsylvania State Society, he says, that " The 
physical and psychological influence of the ovaries upon woman has 
been greatly overrated." And again he says, " In the popular mind 



DISEASES OF THE OVARIES. 449 

a woman without ovaries is no woman." He then gives his own 
views which are that, '' beyond the induction of sterilit}^ and the 
probable absence of menstruation, the deprivation of the ovaries 
after puberty does not change the character of the woman." Bat- 
tey, Hegar, Wells, and Peaslee, are given as confirming this doc- 
trine. The views held by these authors are based upon observations 
of mature women from whom the ovaries have been removed. This 
alone is not a trustworthy source of information, because the results 
obtained up to the present time appear to be quite variable. For 
example. Dr. T. G. Thomas had one patient who w^as passive in 
her sexual relations before her ovaries were removed, but became 
aggressive afterward. On the other hand, Dr. M. A. Fallen, in a 
paper read before the American Medical Association, in June last, 
related the history of a girl who was promptly and completely 
cured of *' hystero-epilepsy " and an incontrollable desire for self- 
pollution by Battey's operation. 

It is true, no doubt, that an individual who has been fully devel- 
oped under the influence of the ovaries, will continue to manifest her 
former attributes of body and mind after these organs are removed, 
but it does not therefore follow that the ovaries were negative in the 
process of developing and maintaining those attributes. One who has 
become blind in middle life will talk familiarly and understandingly of 
objects impressed upon the mind through the sense of sight, but one 
born blind can not comprehend the beauties of a landscape. This 
abundantly proves that mental peculiarities may continue after the 
physical influences which caused them have been removed. Obser- 
vations made from the opposite standpoint give evidence which 
leads to the same conclusions. We find that, if the ovaries are pres- 
ent in a given individual, she will manifest the physical and psy- 
chical peculiarities of womanhood, although all the other sexual or- 
gans may be absent. Women, well developed in all that is pecul- 
iar to the sex, have been observed in whom the uterus and vagina 
were defective, but I have neither seen nor heard of any such per- 
fection of organization occurring when the ovaries w^ere absent. 
Perhaps the strongest argument on this point is the fact that other 
parts of the general system, when modified by the influence of the 
ovaries, are rendered capable of performing the major functions of 
the uterus, as is illustrated in a very striking manner by vicarious 
menstruation and abdominal gestation. 

In this connection, a brief reference may be made to the influ- 
ence of the nervous system in controlling the functions of reproduc- 
tion. The full discussion of this question involves problems in phys- 
SO 



450 DISEASES OF WOMEN". 

iology whicli have not been solved, and are therefore beyond the 
scope of this work. Whether the higher nerve-centers are devel- 
oped to serve the demands of the nutritive and reproductive organ- 
izations, and whether the location of the nerve-centers which preside 
over sexual phenomena is in the cerebellum or the lumbo-sacral 
portion of the spinal cord, are questions which I am not at present 
able to answer. It is sufficient for the present purpose to keep in 
mind that the sexual organs are dependent upon the general nutri- 
tive system for organic support, and that they stimulate, depress, or 
modify nutrition through the ganglionic nerves chiefly, and that the 
portion of the brain which presides over the organic functions also 
dominates the reproductive organs. We should also recognize the 
fact that the emotions are in part dependent upon the sexual organs 
for their development, and on the other hand that the sexual organs 
are largely affected by the emotions. Metaphysicians agree in stat- 
ing that the sexual appetence, which owes its existence almost en- 
tirely to the ovaries, leads to more emotions than any other human 
tendency, and clinical observations afford good evidence to the phy- 
sician, that the emotions affect the functions of the sexual organs in 
a marked degree. Grief, fear, anger, and even great joy are capa- 
ble of arresting menstruation and probably ovulation also. In view 
of this great potentiality of the ovaries in developing certain capa- 
bilities of the brain and nervous system and in influencing their 
functions, it is evident that, in order to maintain harmonious action 
of the whole organization, it is necessary that the ovaries shall exist 
in full development and functional activity. On the other hand, 
these organs which are essential to the well-being of the individual 
must, when diseased, exercise a potent influence in deranging the 
brain and nervous system. 

From a somewhat extended consideration of this subject, I am 
satisfied that a great many affections of the brain and nervous sys- 
tem are due to disease of the ovaries. The remote effects of ovarian 
disease have been observed and recorded to some extent, but not so 
fully, I presume, as they might be. The tendency of observers has 
been to attribute certain mental derangements and diseases of the 
nervous system to the sexual organs in general or the uterus espe- 
cially. A little attention to some of the known defects and diseases 
of the ovaries and their relations to diseases of the brain and nerv- 
ous system will, I think, materially change that phase of the subject. 

Imperfect development of the ovaries not only modifies the phys- 
ical peculiarities of the individual, but also retards the development 
of the higher nerve-centers. The demands of the sexual organs (ec- 



DISEASES OF THE OVARIES. 451 

pecially the ovaries) stimulate the brain to a higher development. 
A very large part of the brain and nerve power is devoted to repro- 
duction, and if that function is never established because of the ab- 
sence of the ovaries, the brain and nervous system are never fully 
developed. When a woman is deprived of the sexual organs the 
nutritive system may possibly attain a normal development, but the 
nervous system does not — it remains upon a lower plane. There is 
usually mental weakness and often derangement of mind among 
those in whom the ovaries are imperfectly developed. Among six- 
teen young single women, that came under my observation in the 
Insane Asylum, I found twelve who had imperfectly developed sex- 
ual organs. Some of them had never menstruated at all, and others 
had done so imperfectly. The history of these cases led to the con- 
clusion that the defective development of the ovaries was an impor- 
tant element in causing insanity. They no doubt inherited an in- 
sane neurosis or diathesis, but the absence of ovarian influence, 
which favors a higher and more complete development of the nerve- 
centers, acted as the major-cause in producing the insanity. This is 
not claimed to be a positively correct deduction, but there is cer- 
tainly strong presumptive evidence that such was the case. The 
mental derangement appeared in the majority of them at or about 
the period of puberty. There was nothing in the size or develop- 
ment of these patients to indicate any marked defect in the nutri- 
tive system. The nervous and sexual system alone were deficient. 
They appeared to have passed through girlhood in a normal way 
(although not manifesting a high order of mental capacity) until 
the period when the sexual organs should have begun to exercise 
their influence in completing the higher development of the nerve- 
centers. When that failed to take place, the brain became deranged, 
instead of assuming new activities. Still it is possible that the im- 
perfectly developed sexual organs resulted from inferior general 
organizations which were from the beginning of a low type, and 
that the insanity which followed was due to transmitted lesions, and 
was not dependent upon the sexual organs at all. However, the 
facts appear to favor the opposite conclusion. One thing is certain 
regarding this subject : there is enough in the nature of the cases 
mentioned to invite further investigation in order to settle, as far as 
possible, the relation of the ovaries to insanity and other diseases of 
the nervous system which occur at puberty. 

As the period of puberty approaches a considerable number of 
Graafian follicles (from twelve to thirty) enlarge, the largest reach- 
ing a diameter of half an inch. In the early stage of development. 



452 DISEASES OF WOMEN. 

it will be remembered, tlie smallest follicles were found in the corti- 
cal layer, those of medium size in the middle layer, and still deeper, 
the larger follicles. These follicles increase in size by the produc- 
tion of an increased amount of liquor folliculi. This so distends the 
wall of the follicle as to cause it to project from the surface of the 
ovary, and to become thinner and thinner until finally it bursts, dis- 
charging the ovum with some of the cells of the membrana granu- 
losa, especially those forming the cumulus proligerus. The ovum 
passes into the Fallopian tube, and through it descends to the uterus. 
This ripening and discharge of ova is the process of ovulation and 
occurs periodically, in the human female about every four weeks. 
As the time approaches in each month for the rupture of a follicle 
there is an abundant formation of vascular loops in connection witli 
increased growth of the membrana propria, which together with 
the liquor folliculi distends the wall of the follicle. Tliis distention 
stimulates the ovarian nerves, and as a result there is an increased flow 
of blood to the ovaries and other organs of generation. The wall of 
the follicle, in addition to being distended, also becomes fatty at its 
most projecting part, and when it is no longer able to withstand the 
internal pressure it bursts and the ovum is discharged. When this 
rupture takes place there is in the liuman female haemorrhage from 
the vessels already spoken of as being found in the interior of the 
follicle. The amount of blood effused is sufficient to fill the cavity 
of the follicle. It soon coagulates, the serum is reabsorbed, the 
hsemoglobin becomes hsematoidin, and after a time the coloring-mat- 
ter disappears. In short, the same changes, take place in tlie blood 
here as when a haemorrhage occui's elsewhere in a closed cavity. 
The wall of the follicle becomes hypertrophied and convoluted, and 
later on undergoes fatty degeneration, with the formation of lutein, 
giving to the structure a yellow color, on which account it has been 
called a corpus luteum. The corpus luteum spurium by which 
name the corpus luteum of menstruation is known, reaches its maxi- 
mum of development at the end of the third week after menstrua- 
tion, at which time it commences to diminish in size until at the 
end of the eighth week it is reduced to an insignificant yellowish 
cicatrix about one fourth of an inch in diameter, but it sometimes 
may be discovered if carefully sought at the end of eight months. 
If, however, the ovum which escaped from a given Graafian follicle 
becomes impregnated, then the process becomes modified in that fol- 
licle. The corpus luteum is then denominated verum instead of 
spurium. The differences between the two varieties of corpora 
lutea are of degree not of kind. The changes which take place are 



DISEASES OF THE OVARIES. 453 

the same in both up to the end of the third week, then, instead of 
diminishing, the corpus luteum verum continues to grow until the 
end of the fourth month when it reaches the height of its develop- 
ment. It retains this maximum until the beginning of the seventh 
month when it commences to diminish, but may sometimes still be 
discovered nine months after delivery. The history of the corpus 
luteum is admirably described by Dalton to whose work on human 
physiology the reader is referred for a detailed account of its forma- 
tion, and the subsequent changes which it undergoes. 

LESIONS OF FORMATION OF THE OVARIES. 

Both ovaries may be entirely absent, or, perhaps, it would be 
more correct to say, entirely rudimentary, or one may exist alone, or 
there may be a third one present. When a single ovary is absent 
the condition of uterus unicornis usually exists, although this mal- 
formation of the uterus is not necessarily accompanied by an absence 
of either ovary. 

The absence of an ovary may be accounted for in different ways ; 
it may not have been developed, it may have been properly formed, 
and by some dislocation of the uterus have had its circulation and 
nutrition so interfered with as to have caused it to shrivel and be- 
come absorbed, or it may have become attached to some other ab- 
dominal organ, and then its absence be only apparent and not real. 

Several cases are on record in which a third ovary has been 
found. The most interesting of these is one which is described and 
figured by Winckel in his work on " Diseases of Women." In 
most of the instances the supernumerary ovary was found near one 
or the other of the normal ovaries, and either behind or in the broad 
ligament. In Winckel's case it was situated in front of the uterus 
and connected with the posterior wall of the bladder. 

As Winckel has so well pointed out, these cases of supernumer- 
ary ovaries are always to be borne in mind in making a diagnosis. 
A cyst forming in the third ovary as found in his case might be de- 
tected between the bladder and the uterus, and be mistaken for 
some other form of tumor. In such cases also the removal of two 
ovaries may not prevent conception, the third ovary being in all re- 
spects normal, and consequently able to discharge ova. So also even 
after two ovaries are removed, should a third exist a cystoma may 
form, which will require operative interference. 



CHAPTER XXY. 

DISEASES OF THE OVARIES. (COI^TINUED.) 

HYPER-aSMIA, ACUTE AND CHRONIC OVARITIS AND PRO- 
LAPSUS OF THE OVARIES. 

Inflammation of the Ovaries. — There are two forms of inflamma- 
tion of the ovaries, the acute and the chronic. These are very dis- 
tinctly different so far as their clinical history is concerned. There 
is another affection closely allied to these which is described by some 
writers as hypergemia. All these are, however, but different degrees 
of the same affection, though each follows a different course and 
gives a history peculiar to itself. This latter fact justifies the con- 
sideration of the acute and chronic forms, at least, of ovaritis as sepa- 
rate affections. The third form, hypersemia, is not so fully under- 
stood nor does it stand out so distinctly from the chronic form as to 
make its description easy. 

Ovarian Hyperaemia. — While many of the characteristics of ova- 
rian hypersemia are like those of ovaritis, there is very good reason 
based upon clinical evidence, to believe that the two are different 
both in pathology and clinical history. 

Ovarian hypersemia, as it is generally observed, resembles many 
of the so-called functional diseases of the ovary, in that there is de- 
rangement of function, with symptoms of organic disease which 
usually disappear, leaving no evidence that there has ever been any 
change of structure or any products of inflammation. All this dem- 
onstrates that the pathology is, as the name implies, a derangement 
of circulation in which there is congestion, and the consequent de- 
rangement of function with the accompanying or resulting pain and 
suffering. The hypersemia usually affects both ovaries, and, as a 
rule, extends to the other pelvic organs, after a time, at least. The 
derangement of function also extends to the uterus giving rise to 
derangement of menstruation. In fact, the congestion and func- 



DISEASES OF THE OVARIES. 455 

tional derangements of the uterus are secondary to the ovarian 
hypergemia. There is much in regard to pathology of this affection 
wliich is inferred from the symptoms, and can not be demonstrated 
by post-mortem investigation. The congestion may be of long or 
of short duration, its continuance depending upon the persistence 
of the causes which give rise to it. If it is well-marked and long- 
continued, it tends to chronic ovaritis, and, perhaps, to degeneration 
of the ovaries and premature atrophy. Should the causes which pro- 
duce the congestion continue active and no treatment be employed, 
the affection may continue indefinitely. The general health be- 
comes undermined by the derangement of the menstrual function 
and the exhaustion of the nervous system ; and if the patient is not 
relieved by treatment or by improved hygienic conditions, she con- 
tinues a sufferer until the menopause. 

"Witli so little that is definite regarding the pathology, one might 
well ask if the fact is yet established that there is a distinct affection 
to be known as ovarian hypersemia. In answer to this, it can only 
be said that the clinical history clearly points to this derangement of 
the circulation as the only rational explanation of the phenomena 
presented in these cases. It should be stated here that there neces- 
sarily must be present in this affection a derangement of ovarian in- 
nervation as well as hypersemia. In fact, it appears that this de- 
rangement is the starting-point in the morbid condition. This 
view of the matter is favored by the affection depending for its 
origin upon perversion of the emotions in those of nervous tempera- 
ment. 

Symptomatology. — Ilypereemia of the ovaries occurs most fre- 
quently among those who are unmarried, or among young widows 
who have never had children. 

It does not come on abruptly like an attack of acute ovaritis, as 
a rule, though it occasionally does so, but is developed rather gradu- 
ally. Those most liable to this affection are the nervous and emo- 
tional who live in conditions of life favoring excitation without 
complete functional action of the sexual organs. I have never seen 
a case of this kind among those who lived under wholesome con 
ditions of life or who were married, bearing and nursing children, 
and who lived quiet, rational lives. At the beginning there are 
pain and heaviness in the region of the ovaries, usually accom- 
panied by much nervous disturbance of the nature of irritability and 
weakness, the patient being easily excited and as easily fatigued. 
Soon after the appearance of these symptoms the menstrual func- 
tion becomes deranged. There is usually menorrhagia, which is 



456 DISEASES OF WOMEX, 

preceded by increase of the ovarian pain. Sometimes the pain is 
relieved and the patient feels much better during the menstrual 
flow, and for a tirtie after it ceases. In some cases the first symp- 
tom developed is derangement of the menstrual function, gener- 
ally too frequent, and too free menstruation. In a word, menorrhagia 
is the most prominent symptom of ovarian hypersemia. The free 
flow being due originally to the ovarian excitation is conservative 
at first, I believe, relieving the congestion which produced it. I 
have frequently seen young women, who apparently suffered from 
ovarian congestion, recover completely after one or more free at- 
tacks of menorrhagia. When the excessive menstruation does not 
relieve the congestion, which it certainly will not do if the causes 
which produced it are continued, then it leads to anaemia and neu- 
rasthenia, and this state of health may continue indefinitely. 

There are other symptoms which may be mentioned, as backache 
and general pelvic tenesmus, increased on walking sometimes, but 
not always. In the less severe forms of hypersemia of not very 
long standing, active muscular exercise gives relief not for the time 
only, but is oftentimes permanently beneficial. There is often irri- 
tability of the bladder, which is purely nervous. 

Physical Signs. — There is tenderness on deep pressure made in 
the iliac regions, not acute, but of that dull character which is pecul- 
iar to the ovaries. As the disease aifects both ovaries, as a rule, 
there is tenderness alike on both sides. 

Bimanual examination usually shows tenderness better than ab- 
dominal pressure, but I have found that in these cases it is very diffi- 
cult to grasp the ovaries between the two hands, owing to the fact 
that the abdominal muscles are tense ; while in the majority of cases 
there is tenderness if pressure is made upon the ovaries, either 
through the vaginal or abdominal walls, I have seen many cases in 
which steady but not too heavy pressure in the iliac regions gave re- 
lief. Perhaps these were cases of the kind that Charcot calls hys- 
tero-epilepsy, in which the convulsions are relieved by pressure upon 
the ovaries. I have seen some of Charcot's cases, and believe them 
to be ovarian hypersemia. 

The physical signs obtained are rather negative, but by excluding 
the evidence of other ovarian affections, and taking the history into 
account a presumptive diagnosis can be made, and the diagnosis will 
be confirmed by the subsequent history. Under treatment and im- 
proved moral and physical hygiene, recovery will take place much 
more promptly and completely than in chronic inflammation. 

In connection with this affection of the ovaries, especially if it 



DISEASES OF THE OVARIES. 457 

has existed for several montlis, tLere is nsuallj congestion of tlie 
uterus and vagina which yields promptly to treatment. 

Prognosis. — The great majority of patients recover under appro- 
priate treatment. In fact, many of them recover after the causes 
are removed without any treatment whatever. This will be seen in 
the history of the cases given further on. 

Causation. — Overstimulation of the emotions in those of a nerv- 
ous temperament is one of the chief causes of ovarian congestion. 
This is operative among those who are not usefully employed, but 
are permitted or even encouraged to tui^n their attention to the 
procreative function while they are still undergoing development. 
Stimulating tonics which create an appetite which is not satisfied 
with food will cause gastric congestion, and all the consequences 
which arise therefrom. In like manner stimulating the sexual 
appetence of unoccupied emotional young girls by evil influ- 
ences or improper associations leads to ovarian congestion. Those 
who have lived in the proper exercise of the sexual function, but 
have been abruptly cut off from normal gratification, are prone to 
ovarian congestion. Indulgence beyond normal gratification is also 
said to have produced the same result. All these causes are, to a 
great extent, psychical, but ovarian congestion may be produced by 
purely physical causes. It may be secondary to endometritis, seden- 
tary habits, and constipation, which may interrupt the free circula- 
tion in the pelvic organs. 

It is rare, however, that cases of ovarian congestion can be traced 
to such causes. 

Treatment. — The removal of the cause, when that can be accom- 
plished, is, as I have already said, often sufiicient to give relief. 
The termination of an engagement in marriage has cured the men- 
orrhagia in many cases, and complete recovery has followed when 
pregnancy occurred. 

A like good has been brought about in younger patients by di- 
recting the attention to something other than self and the feelings 
and emotions. A change from books and society to the woods and 
fields, and out-door occupation in the way of amusements should be 
employed. Bathing is useful — either sea-bathing or the shower-bath 
— if the patient is strong enough to bear it. Tonics to restore the 
general strength, mix- vomica being the most efiicient ; counter- 
irritants, ergot and bromides complete the list of therapeutic agents. 

The tonic and ergot should be given through the day, and the 
bromide at night to secure rest and sleep. 

Acute Ovaritis. — This is quite distinct from other ov^arian affec- 



458 DISEASES OF WOMEN". 

tioTis, because it is probably always the result of some special cause 
— usually a specific poison, such as gonorrhoeal infection, puerperal 
septicaemia, or some constitutional condition like that which exists 
in the eruptive fevers and in acute rheumadsm. It may also be 
traumatic, though that is rare, except when the ovaries become in- 
volved in a general pelvic inflammation due to an injury. There 
has been and still is much confusion of thought regarding the pa- 
thology of ovaritis. Some of the conflicting accounts arise, I 
presume, from confounding acute and ehronic ovaritis and ovarian 
hypergemia. There is, no doubt, so marked a resemblance between 
these three afl:'ections, and they are so often associated that it is im- 
possible to dilferentiate them in many instances. Still, between the 
typical causes of each, met occasionally in ^^ractice, the distinction 
can be easily made. The acute affection runs its course rapidly, and 
terminates either in death or a subsidence of the acute inflammatory 
symptoms and a damaged state of the ovaries. There are well-defined 
symptomatic forms, and the changes of sti-ucture which result in 
connection with the clinical history are such as belong to acute 
inflammatory action. In chronic ovaritis there are, on the con- 
trary, changes which take place much more slowly, and are not 
marked by the same definite jjroducts of inflammation. In conges- 
tion of the ovaries there are no tissue changes. It appears to me 
that acute and chronic ovaritis are as well defined, both in clinical 
history and anatomical changes, as acute and chronic nephritis. 
There is still much need of more observation and careful comparisons 
of the clinical history and post-mortem appearances in order to settle 
more definitely the pathology of acute ovaritis. 

Pathology. — 'When ovaritis occurs in connection with the puer- 
peral state, only one ovary is affected as a rule. All the tissues of 
the ovary take part in the congestion, which is the first morbid 
change produced. Following the congestion there is swelling from 
the transudation of serum, which is often of a reddish color. The 
inflammation involves all the tissues ; the vesicles, stroma, parenchy- 
ma, and the envelope, and not infrequently the fimbriated extremity 
of the Fallopian tube is involved, and the peritonaeum around the 
ovary. Then the ovary becomes surrounded with the exudate, so 
that from the gross appearances it is not possible to tell whether the 
ovary or the peritonaeum was first attacked. The changes in the 
ovary are, in addition to general serous effusion, destruction of the 
vesicles from effusion or purulent infiltration ; sometimes one large 
abscess is formed in the ovary which destroys most of the tissues ; 
m other cases a number of small abscesses are found. In short, 



DISEASES OF THE OVARIES. 459 

acute ovaritis is general as a rule, but occasionally partial ovaritis 
occurs. From what Las been said, it will appear that ovarian inflam- 
mation is, in its morbid anatomy, similar to adenitis generally. The 
congestion, serous effusion, suppuration, the formation of single or 
multiple abscess, and plastic exudations on the free surface of the 
ovary are the usual clianges. These changes are manifested in dif- 
ferent degrees at various parts of the ovary, due in part to the course 
which the disease follows, but more especially to the different struct- 
ures or elements which compose the ovary. In addition to these 
pathological changes, there are others which may or may not occur. 
There are prolapsus of the ovary and adhesions to neighboring organs. 
The abscess may open into the rectum or the peritoneal cavity, or 
find its way into the lymphatics or veins, wliich are often dilated; 
quite frequently the abscess does not discharge at all, but remains 
encysted. 

Symjptomatology. — There are both local and constitutional symp- 
toms in acute ovaritis. There may be a chill or rigor, followed by 
fever, nausea, vomiting, and pain more or less acute. The acuteness 
of the pain appears to be greatest when the peritonseum is affected. 
There is marked disturbance of the nervous system, shown by irri- 
tability and anxiety, but no delirium ; not infrequently, however, 
hysteria and, in a few cases, mania have been developed. 

The only difference which I have noticed between the symp- 
tomatic form of ovaritis and other acute pelvic inflammation is that 
in the former the nervous symptoms are more marked. In mild 
forms of this affection the constitutional disturbances are less severe ; 
still there is an elevation in the temperature, increased frequency 
of the pulse, and deranged primary nutrition. The appetite is poor, 
and there are dyspepsia, flatulence, and constipation. The symp- 
tomatic form subsides to some extent after the flrst few^ days, and 
the formation of pus reawakens the general disturbances. There 
may be a chill, followed by perspiration, or irregular rigors may 
occur, and the pain may return more acutely. The local s^miptom 
is pain, which is often circumscribed, the patient being able to point 
out the exact spot in the iliac fossa where the pain starts, and from 
which it radiates, and where the tenderness is felt on pressure. There 
are pelvic tenesmus, and a frequent desire to urinate, and, if the left 
ovary is the one affected, there is often excruciating pain during 
defecation. 

Physical Signs. — There is acute tenderness on pressure, more 
definitely located than in pelvic peritonitis. Sometimes the ovary 
can be felt through the abdominal walls. This is frequently the case 



460 DISEASES OF WOMEN. 

when the ovary is greatly enlarged by the products of the inflam- 
mation, and is fixed high np by adhesions. By the vaginal touch 
heat and tenderness are detected. Pressure causes pain of a char- 
acter peculiar to the ovary. The finger should be carried high up 
behind the uterus, when the ovary may be caught between it and 
the sacrum. By very gentle manipulation the uterus and the 
ovary also, perhaps, are found to be movable to a limited degree. 
The location of the tumor, its partial mobility, its form, and 
that it is not connected directly to the uterus, all go to aid in 
making the diagnosis. The rectal touch will enable the examiner 
to locate it. 

Differentiation. — Owing to the fact that, m the present state of 
science regarding this affection, the diagnosis is not at all times easy 
to make, it is necessary to mention the conditions which resemble it, 
and point out the differences which help to define and distinguish 
acute ovaritis from them. Acute ovaritis is easily distinguished 
from chronic ovaritis and hypereemia by the absence in the latter 
of symptomatic fever. Much aid is obtained by the history which 
nearly always presents some of the causes which give rise to acute 
ovaritis. 

It may be distinguished from pelvic peritonitis and celluHtis by 
the physical signs. The fixation of the uterus and the more diffuse 
distribution of the inflammatory products being most marked in the 
cellular and peritoneal inflammation. In cases of acute ovaritis that 
are complicated with cellulitis or peritonitis, the differential diag- 
nosis can not be made upon the liWng subject. That these affections 
have occurred together can be determined, but which was the pri- 
mary affection can only be surmised from the history. 

Prognosis. — When suppm-ation occurs, and the abscess opens 
into the peritoneal cavity, a fatal termination should be expected. 
Death may also occur from septicaemia when the contents of the sac 
of the abscess flnd their way into the lymphatics or veins. This, 
I believe, is more likely to occur when there are a number of small 
abscesses with thin walls. If the accumulated pus is discharged 
through the rectum or vagina, or if the abscess becomes encysted, 
recovery may take place. The ovary is, of course, damaged or de- 
stroyed, but, if one ovary is left in a normal state, the patient may 
regain health and bear children. In some cases of chronic suppura- 
tion, in cases where the pus is discharged through the rectum or 
vagina, or is walled in by peritoneal adhesions from plastic exuda- 
tion, relief may be obtained by surgical means to be referred to 
when discussing the treatment. 



DISEASES OF THE OVARIES. 461 

Causation. — The causes of acute ovaritis iiave already been 
named. 

Puerperal septic absorption and gonorrhoeal infection are tlie 
chief causes. Lawson Tait has called attention to the eruptive fevers 
and acute rheumatism as giving rise to acute ovaritis, and mj own 
observations agree with his in the main. 

While I have not seen ovaritis occurring in connection with rheu- 
matism, I have seen several cases caused apparently by the eruptive 
fevers. I have never seen ovaritis due to traumatic causes, still I 
can believe that such might be the case. 

Treatment. — In regard to the management of acute ovaritis, I 
may say, in brief, that the cases that have come under my care have 
been treated exactly as I have treated pelvic peritonitis or cellulitis. 
I have not discovered any special line of management as specific 
medication ; hence, to avoid useless repetition, I must refer the reader 
to the treatment of the above-named affections. 1 may remark in 
passing that, knov/ing that the causes are specific in the majority of 
cases, care may be taken to prevent the occurrence of ovaritis by 
judicious treatment of the affections which give rise to it. There 
is room for doubt, however, if much can be accomplished in this 
way. 

Chronic Ovaritis. — Pathology. — The study of the pathology of 
ovaritis derives a special interest from the fact that the ovary differs 
from all other organs of the body, in that its function is performed 
at the expense of a portion of its structure which is never restored 
to its original condition. The rupture of each Graafian vesicle in 
ovulation causes the destruction of the vesicle. Rudimentary vesi- 
cles mature and repeat the function of their predecessors, and are in 
turn destroyed. Finally, the supply ceases, and the ovary, worn out 
in structure, becomes functionally incompetent long before the gen- 
eral organization has reached the end of its life and activity. In all 
other organs of the body function is effected through cellular disin- 
tegration and restoration. 

This peculiarity in the natural history of the ovary makes it dif- 
ficult for the superficial observer to distinguish between the normal 
degeneration and the structural changes which result from chronic 
ovaritis. Experts also find it no easy matter to distinguish, by gross 
appearances, the atrophy of old age from the cirrhosis of infiamma- 
tion. 

The pathology of ovaritis is characterized by changes of struct- 
ure brought about chiefly by areolar hyperplasia first, then by atro- 
phy of the normal tissues, and finally by a condition of cirrhosis. 



462 DISEASES OF WOME^\ 

In this respect the morbid process and its products more resem- 
ble degeneration than inflammation such as is observed in other 
organs. In the natural history of its pathology chronic ovaritis is 
more like certain forms of chronic nephritis. Giving to these 
peculiar and distinguishing features, the affection has little in com- 
mon with acute puerperal or non-puerperal ovaritis, or with sec- 
ondary acute ovaritis due to peritonitis, and therefore all such 
conditions will be carefully excluded from the discussion of the 
subject in hand. 

The first variation from the normal toward the pathological is 
deranged innervation ; the ovary, owing to its important ofiice and 
intimate relations to the other organs, being peculiarly prone to re- 
flex disturbances. These, though temporary as a rule, when oft re- 
peated and prolonged in duration, induce changes in the circulation 
which impair nutrition and finally produce changes of structure. 
This ovarian hyperaemia, the first step in the process, may subside, 
and complete recovery follow. Reliable evidence of this has been 
obtained, first by clinical observation of cases which have given all 
the signs and symptoms of ovarian congestion, and which, under 
careful management, have completely recovered. 

Secondly, by inspection after laparotomy. I have not infre- 
quently found a prolapsed, tender, and painful ovary, which upon 
inspection was markedly hypersemic, but presented no apparent 
change of structure except oedema. After fixing it in place by 
stitching the utero-ovarian ligament to the upper border of the broad 
ligament, the signs and symptoms have all subsided. The continu- 
ation of the hypergemia slowly produces those structural changes 
which are invariably effected by prolonged mal-nutrition. The first 
noticeable changes take place in the blood-vessels themselves. They 
become dilated, and a peculiar degeneration of their walls occurs. 
These changes have been elaborately studied by Dr. E. Xoeggerath, 
who advanced the idea that these vascular changes were closely re- 
lated to the genesis of ovarian cystomata. This may be true in cer- 
tain cases, but it more frequently ends in areolar hyperplasia of the 
stroma, which gradually goes on, and in time crowds out all the nor- 
mal structural elements of the ovary. Finally, a true cirrhosis is 
produced. With these changes in the blood-vessels the circulation 
is interrupted to a degree that causes oedema, which increases the 
size of the ovary and renders it softer. Apoplexies sometimes oc- 
cur, and occasionally one or more of the blood-clots may be seen 
near the surface. These conditions can be distinguished from a dis- 
eased vesicle by the staining of the tissues around the clot. This 



DISEASES OF THE OVARIES. 463 

last-mentioned lesion occurs in the early stage of tlie ovaritis, and 
gradually disappears as the process of hyperplasia proceeds to a 
complete cirrhosis. These changes explain some of the important 
facts in the clinical history. The ovary which is found enlarged, 
softened, and tender to the touch, will, in months afterward, appear 
subnormal in size. Likewise the same lesions may be recognized 
upon inspection after laparotomy, if one has become familiar with 
them by previous study. 

While hyperplasia of the stroma is going on, the follicular ele- 
ments undergo certain changes. The contents of the follicles be- 
come cloudy from degeneration of the epithelial elements. The 
gross appearance of the ovary at this time would lead one to sup- 
pose that there were a number of vesicles approaching maturity, 
but the uncommon number of these is evidence that they are ab- 
normal. 

The full value of a knowledge of the gross pathology of ovaritis 
can be fully estimated by those who have mistaken the normal for a 
pathological degeneration of the ovaries, and have removed them, to 
learn subsequently, through the microscopist, that they were not 
diseased. The morbid appearances which aid the surgeon in decid- 
ing when to remove an ovary and when not to remove it are as fol- 
lows : The presence of follicles which, from their size, number, and 
dark color, are evidently diseased : enlargement, congestion, and 
softening from oedema, and patches of induration, with irregular 
distention of the vessels and the evidence of small blood-clots, as 
described above. Cirrhosis, indicated by subnormal size, indura- 
tion, and irregular surface, when found in a young subject, can 
be easily passed upon. But in a subject near or after menopause 
this appearance of the ovary does not enable the surgeon to decide 
with certainty whether there is cirrhosis or simply senile atrophic 
degeneration. 

Symptoinatology. — The history of chronic ovaritis includes both 
local and constitutional symptoms. The constitutional derange- 
ments are not acute, but are usually marked by depression of the 
nutritive and nervous systems. The reflex derangement of the 
digestive organs is manifested by capricious appetite, nausea, and 
sometimes gastralgia. The bowels are usually constipated and 
tympanitic. There is often nervous debility attended with great 
emotional disturbance. I believe that I have seen more marked de- 
rangement of the brain and nervous system caused by chronic ova- 
ritis than by the reflex influence of any other affection of the sexual 
organs. These constitutional symptoms are progressive, the patient's 



464 DISEASES OF WOMEK 

general health becoming more impaired month after month as the 
disease advances. The local manifestations are pain and derange- 
ment of menstruation. There is often menorrhagia ; in fact, that is 
the rule, but in cases of long standing I have seen amenorrhoea. The 
ovarian pain is usually increased for several days before menstrua- 
tion, and is relieved to some extent when the flow has lasted a day 
or two. The menstrual pain is much more severe and persistent if 
there be a uterine disease accompanying that of the ovaries. The 
ovarian pain varies according to the ovarian tissue affected. When 
the stroma alone is the site of the disease the pain is less severe. 
Much more suffering is experienced when there is circumscribed 
peritonitis or salpingitis. 

All these symptoms are aggravated by standing, walking, riding, 
or sitting in a stooping position for any great length of time. Most 
comfort is obtained by the recumbent position. Sexual excitation 
and coitus cause so much suffering that the patient shrinks from 
both. There are exceptions to this rule, but not many. 

Physical Signs. — The ovaries are tender to the touch, and the 
pain excited by pressure lasts for a long time as a rule. The char- 
acter of the pain excited by the touch is described as ovarian. 
When the ovary is enlarged or changed in form it can sometimes be 
made out by the bimanual touch. The ovary is usually movable, 
and its separation from the uterus can be distinguished. It will be- 
observed that the symptoms and physical signs of chronic ovaritis 
closely resemble those mentioned as occurring in ovarian hyper- 
semia. The fact is that the two affections have many features in 
common, hypersemia being a part or the initial stage of inflamma- 
tion, the manifestations of the two affections are similar. 

Between ovaritis and ovarian neuralgia there is a close resem- 
blance, but the differences are also equally marked. In neuralgia 
there is no evidence of inflammation, it is not continuous, and very 
often the ovary is not tender. The diagnosis can only be made by 
a due consideration of the history as related to the cause, duration, 
physical signs, symptoms, and progress of the affection. 

Prognosis. — If the patient has the good fortune to be placed 
early under treatment, the chances of recovery are favorable. This 
is still more certain if only one ovary is affected. The disease may 
go on in one ovary to complete destruction of the organ by hyper- 
plasia of its cellular tissue and atrophy of its glandular elements, 
and after this premature atrophy all suffering may subside except 
occasional neuralgic pain ; and the other ovary may perform the 
ovarian function. In case the disease is complicated with inflamma- 



DISEASES OF THE OVARIES. 465 

tion of the neighboring peritonaeum, and there is marked destruction 
of tissue from the inflammation, relief can only be given by remov- 
ing the ovaries. There is not a great mortality from this affection. 
I have never seen a fatal case, but I have seen several in which life 
was not worth living. 

Causation. — The causation of chronic ovaritis demands a brief 
notice, owing to its intimate relation to the question of treatment. 
According to my observations, the cause which most frequently ob- 
tains, is imperfect menstruation. When the uterus is undersized or 
flexed forward or backward, and the menstrual flow is scanty and at- 
tended with pain, the ovaries are liable to take on chronic inflamma- 
tion. This is far more liable to occur in this class of subjects if the 
sexual function is perverted. Specific causes such as produce the 
eruptive fevers are said to affect the ovaries, but I believe that acute 
ovaritis is more liable to occur under these circumstances. It is 
probably true, also, that gonorrhoea causes acute rather than chronic 
ovaritis. 

The strumous diathesis (which I understand to be that condition 
of organization which invites tuberculosis) predisposes to chronic 
ovaritis, and inherited or acquired syphilis does likewise. 

Much has been written about endometritis as a cause of ovaritis, 
upon the theory that the structure of the endometrium and that of 
the ovaries have a common embryonic genesis, and the fact that the 
two diseases are often found together, but this is still an open ques- 
tion. 

Surgical Treatment. — The advancement of abdominal and pel- 
vic surgery in recent times has led to the removal of the ovaries 
as the most prompt and effectual treatment of chronic ovaritis. 
There are reasons for this upon theoretical grounds. The ovary is 
causing much suffering ; there is a likelihood that it will be a long 
and tedious trouble ; especially is this the case if general treatment 
has failed; the ovaries are not necessary to existence, and can be 
removed with safety; it is according to the rules of surgery to 
remove any organ, or other portion of the body, that one can live 
without, in case a disease of the part tends to take life or cause 
unlimited suffering and invalidism ; hence, from this way of look- 
ing at the matter, the ovaries should be removed. 

The facts are (facts that have been proved almost sufticiently), 
that chronic ovaritis does not end fatally, and is self-limited though 
often of long duration ; the removal of the ovaries is not free from 
all danger, though all cases properly operated upon have recovered, 
and it does not in all cases give complete relief. In fact, many of 
31 



466 DISEASES OF WOMEN. 

the cases are not much improved, if at all ; even those who are near- 
ing the menopause, and who bear the loss of the ovaries better than 
younger subjects, occasionally suffer much from those nervous dis- 
turbances which follow an abrupt menopause, and have to endure 
pelvic pain in the region of the stumps. Tlie clinical history of 
cases in which the ovaries have been removed does not, in all cases, 
show great advantage over those in which the ovaries are left to 
complete the natural history of the disease. 

Younger subjects do not bear the loss of their ovaries well. 
Some become fat, indolent, inefficient, and subject to headaches; 
others are irritable, dyspeptic, and despondent ; while but few enjoy 
good general health and mental vigor. 

This statement is at variance with much of the published litera- 
ture, but is more in accordance with the actual facts. The cases 
cured are those operated on when near the menopause ; those who 
are improved are generally those who suffered from complicating 
affections, such as dysmenorrhcea ; while the unimproved are the 
younger subjects in whom the disease was uncomplicated. 

The objections to surgical treatment apply to the removal of 
both ovaries. In cases in which one ovary alone is aifected, and 
especially where there is prolapsus of the affected ovary and retro- 
displacement of the uterus, ovariotomy is perfectly satisfactory. 
The removal of the diseased ovary gives relief, and the retro-dis- 
placed uterus can be restored, while the remaining ovary performs 
its functions, and the general health of the patient is preserved. I 
desire to be understood as advocating the removal of the ovary only 
when there are structural changes from inflammation and prolapsus 
at the same time. Prolapsus can be relieved by fixing the ovary to 
the upper border of the broad ligament, and the welfare of the 
patient can be thus conserved to a higher degree. When advocat- 
ing conservative measures in regard to abdominal and pelvic surgery 
it may be inferred that I am behind the age in experience, but I have 
had a large field for operative surgery, and have acted to the fullest 
extent justifiable, according to my judgment. In fact, I have in the 
past violated the rules I now advocate, but I have not been satisfied 
to have my patients simply survive the operations. I require that 
they be cured, and failures in this regard have led, I trust, to a ra- 
tional conservatism. 

I have no word of condemnation for those who have removed 
and are still removing ovaries for the relief of chronic ovaritis. 
Their work, while not always beneficial, has been of vast interest to 
science. Their doings help to perfect surgery. The rough, un- 



DISEASES OF THE OVARIES. 467 

sightly scaffoldings employed by builders are temporary necessities, 
which are all cleared away when the structure is perfected and 
completed. In like manner the heroic, daring experiments of the 
surgeon are valuable stepping-stones which lead to mature science 
and art. 

General Treatment. — The indications for general treatment are to 
lessen the blood-supply and relieve pain by correcting the deranged 
innervation. This demands rest in the recumbent position in the 
early stages. At the same time general exercise should be enjoined, 
either by massage or gymnastic exercise in the reclining position. I 
specially desire to commend systematic calisthenics, in the recumbent 
position, as a most valuable aid in improving or maintaining the gen- 
eral health in many diseases of the pelvic organs which require rest 
as an important part of the treatment. The condition of the diges- 
tive organs should be carefully watched. The poor appetite, coated 
tongue, and constipation, or the capricious appetite, flatulence, and 
occasional diarrhoea, can be relieved by a number of small doses 
of mercury and a laxative. The saline laxatives are the best when 
they act without causing flatulence. The use of Saratoga waters 
often gives good results by improving digestion and keeping the 
portal circulation active. By keeping up a free elimination by the 
bowels and kidneys much benefit is obtained. This applies in cases 
that are apparently debilitated. Many times I have stopped the 
use of tonics, stimulants, and forced feeding, and given saline laxa- 
tives, with the effect of increasing the patients' strength. To re- 
lieve the pain and lessen the hypersemia, the bromide of sodium and 
fluid extract of hydrastis canadensis are by far the most potential 
agents that I have found ; they are given in combination, and in 
doses sufficient to produce the desired effect. Twenty to thirty 
grains of the bromide and ten to twenty minims of the hydrastis, 
three times a day, until the physiological effects of the bromide are 
noticed in a mild degree. If the hydrastis is given alone, in such 
doses, it sometimes causes pelvic pain of a dull character, but when 
combined with the bromide it has no such effect. These agents are 
most efficacious in the beginning of the attack, and hence they should 
be discontinued as soon as the pain is relieved in a marked degree. 
Should the pain and tenderness return at the succeeding menstrual 
periods, the bromide and hydrastis should be resumed. In some 
cases much larger doses of bromide are required, and in others it 
fails altogether to relieve pain. Then it is necessary to employ 
other agents, especially during menstruation. Ten-grain doses of 
salicylate of soda and five of antipyrin, given between meals and in 



46e^ DISEASES OF WOMEi^f. 

the night, when the stomach is empty, answer for some ; others, 
more especially those markedly debilitated, do better on full doses of 
aromatic spirits of ammonia, camphor, and chloric ether, with small 
doses of cannabis Indica This combination is best suited to those 
who get relief from gin or whisky, but it is to be preferred, as al- 
coholic stimulants ultimately do harm, though they may give tem- 
porary relief. Direct or local treatment should be adapted to the 
social state of the patient, and the presence or absence of complica- 
tions, such as endometritis. In the unmarried, local treatment is 
often injurious. In fact, in such cases it is better to avoid any ex- 
amination of the pelvic organs, if the history is sufficiently clear to 
enable one to make a diagnosis with reasonable certainty. Hot sitz- 
baths, counter-irritation, and hot vaginal douches, the latter to be 
employed by a competent nurse, comprise about all that I employ 
in the way of direct treatment The vaginal douche should not 
be continued unless it is decidedly sedative in its effects. Baths 
used according to the rules of modern hydrotherapy are of great 
service. 

In weak, nervous patients I begin with the wet-pack, used for 
half an hour at a time. Those who require a sedative are put into 
water at a temperature of 95° F, for ten or twenty minutes and then 
dried by brisk rubbing. When the sedative effects of the bath are 
no longer needed, the tonic bath should be used. This consists of 
the cold sponge, shower, or plunge bath. The water should be warm 
at first, and gradually reduced in temperature at each bath. 

In married women (and those who are so in all but the name) 
local treatment is more valuable. The treatment of any disease or 
displacement of the uterus that coexists should be managed in the 
usual way, and such local applications should be used as may aid in 
relieving the tender and hypersemic ovaries. I employ a small tam- 
pon or pledget of cotton or wool saturated with equal parts of tinct- 
ure of belladonna and glycerin, applied behind the cervix uteri and 
permitted to remain forty-eight hours, and after its removal a hot 
douche. These are continued during the first days of treatment. 
The effect is to support or steady the ovaries, while the sedative ef- 
fect of the belladonna and the depleting effect of the glycerin are 
obtained- This I have followed with applications of tincture of 
iodine, after the manner of Dr. Emmet. Recently I have used, with 
good effect, the sulphichthyolate of ammonium, five parts in nine- 
ty-five of glycerin, applied in the same way as the belladonna and 
glycerin. 

The general and local treatment thus briefly outlined gives re- 



DISEASES OF TOE OVARIES. 467* 

lief from the more pronounced symptoms. The pain becomes less, 
and the tenderness also. The general health improves, and the pel- 
vic congestion subsides. This is apparent in the color of the mucous 
membrane, the improvement of the menstrual functions, and the 
diminished leucorrhoea. Then the local treatment may be employed 
at longer intervals, or suspended altogether. The constitutional 
treatment should now be modified. Tonics and laxatives may still 
be required, but alteratives are also indicated. Iodine and mercury 
are the chief agents. They act upon the ovaries, as they do upon all 
glandular organs, and modify or arrest the morbid histological 
changes which take place slowly. Small doses of bichloride of 
mercury, with chloride of iron, when iron is indicated, followed by 
syrup of the iodide of iron in doses as large as can be borne. These 
can only be used when the bromides are relinquished. When giv- 
ing these alteratives the patient often misses the bromides used to 
produce sleep. Sulphonal at such times is of great value. In fact, 
it is the most potent sedative that is at the same time free from 
ultimate or after effects that are unfavorable that we have in gynae- 
cological practice. When a sedative is required while iodine or 
mercury is being used, I find that ten grains of salicylate of sodium 
and five grains of antipyrin, three times a day an hour before meals, 
give much relief, especially in those who suffer from nervous dys- 
pepsia and flatulence. 

Important elements in the treatment are patience and careful 
watching. Improvement comes, and the patient or the physician 
gives up treatment, and there is danger of relapse. The poor in 
hospitals often suffer for want of time for prolonged treatment, and 
this frequently tempts the surgeon to seek more prompt relief by 
removal of the ovaries. This does not apply with the same force 
to those who have time and means to secure the needed care. 

The description of the operation for the removal of ovaries de- 
stroyed by inflammation, as well as that for the removal of diseased 
tubes, will be found at page 552. 

Displacement of the Ovaries. — The ovaries have been found dis- 
located in a variety of ways. Cases are recorded in which the ova- 
ries descended through the inguinal canal after the manner of the 
testicles. The most interesting of these is one reported by Percival 
Pott, who removed both ovaries that were found in the nsual posi- 
tion of an inguinal hernia ; and still another is mentioned by Tait, in 
which the ovary found its way ontside of the inguinal ring and there 
developed a cystic tumor, which was removed by a Spanish surgeon. 
The ovaries have been found dislocated laterally and high up in the 



468 DISEASES OF WOME^^. 

pelvis. They are, in such cases, usually fixed in the malposition by 
adhesions. 

Prolapsus of the Ovaries. — Downward dislocation of the ovaries 
is quite a common aifection compared with all the other displace- 
ments. It is the only affection of this class which has an interest 
to the gynecologist derived from the frequency of its occurrence and 
the great suffering to which it gives rise. On that account it de- 
serves more than a passing notice, such as I have given to the other 
forms of displacement of the ovaries. 

Prolapsus of the ovaries I have described as occurring in two 
degrees — complete and incomplete. This classification is based upon 
the fact that displacements of the ovaries must in practice have the 
natural division. In the incomplete form the ovary has simply de- 
scended from its normal position until it has reached the side of the 
sac of Douglas or the utero-sacral ligament, where it lodges. In the 
complete form the ovary rests in the most dependent portion of the 
sac of Douglas. Fig. 1S9 shows the position of the ovary in com- 





FiG. 189. — Ovary displaced and bound down in the cul de sac by adhesions, ro, right 

ovary ; /o, left ovary. 

plete and incomplete prolapsus, and the relation of the prolapsed 
organ in relation to the uterus and sac of Douglas. The figure 
also shows what is sometimes found in practice — namely, complete 
prolapsus of one ovary and incomplete prolapsus of the other occur- 
ring in the same subject. AYhile prolapsus of both ovaries in dif- 
fering degrees, or both in the same degree, may occur, I more fre- 
quently find one displaced, while the other is in its normal positioiL 



DISEASES OF THE OVARIES. 469 

The left is the one most frequently displaced, or else it causes the 
most suffering, and on that account attracts more attention than the 
right, and is oftener discovered. 

Prolapsus necessitates a stretching of the supports of the ovary, 
or it may be an elongation from an increase of tissue, the result of 
hyperplasia or new development. Prolapsus does occur without 
complications or coexisting affections, which cause the displacement. 
Such cases are not very common, and they are probably the result 
of arrest of development. In many cases, perhaps the majority, 
there is some accompanying affection which has some part in the 
causation of the prolapsus. The ovary itself is often enlarged from 
inflammation or some degenerative changes. In other cases the sup- 
ports of the ovary are elongated from imperfect involution after con- 
finement. Retroversion of the uterus is also frequently associated 
with prolapsus of the ovary. A not uncommon and a very unfor- 
tunate complication is the formation of adhesions from peritoneal 
inflammation. 

Symptomatology. — The degree of suffering arising from disloca- 
tion of the ovaries is extremely varying in different cases. This is 
due largely to the fact that, if the ovaries are quite normal and sim- 
ply displaced, but little inconvenience is experienced by the patient. 
It is rare to find this state of things, because the ovaries are often 
diseased, or else displacement soon leads to congestion, tenderness, 
and pain. As a rule, then, in displacement of the ovaries there is 
pelvic tenesmus and pain on walking or standing, relief from which 
is obtained hy the recumbent position. In this the history differs 
from inflammation of the ovaries. There is usually backache and pain 
along the thighs, and pain and tenderness during and after sexual 
intercourse. There is pain after defecation, especially when the left 
ovary is displaced, which is most frequently the case. This pain is 
peculiar and, I believe, diagnostic. It comes on during or imme- 
diately after the action of the bowels, and continues for an hour or 
two. It is a dull, aching pain located in the region of the ovary, 
and radiates to the abdomen. It produces in many cases faintness 
and nausea, compelling the patient to lie down until it subsides. It 
is easily distinguished from the acute, smarting pain due to haemor- 
rhoids or fissure of the anus, on account of its location and character. 
There is in some cases derangement of menstruation, usually menor- 
rhagia. The pain in the ovary is generally aggravated at the men- 
strual period. The constitutional symptoms are generally produced 
from the confinement of the patient, made necessary by the suffer- 
ing caused by taking active exercise. There is often headache. 



470 DISEASES OF WOMEN. 

mental depression, indigestion, and anaemia, ending in general de- 
blKtj. It should be understood tliat the symptoms alone will not 
suffice to make a diagnosis, because in many cases they arise more 
directly from the condition of the ovary rather than from its mal- 
position. 

Physical Signs. — The method of making a vaginal examination 
by the touch, to detect a prolapsus of the ovaries is as follows : The 
linger should be carried as far upward on either side of the cervix 
uteri as the vaginal wall will permit, and then brought downward 
toward the sacrum, so that if the ovary is displaced it will be caught 
between the examining hnger and the sacrum. In that way it can 
be outlined by palpation, and its sensitiveness determined. Its 
mobility or fixation can also be determined in this way. I have 
frequently found while teaching my class of post-graduates that 
these few hints would enable them to find the displaced ovaries 
when they had tried in vain to make out their location. When an 
ovary is completely prolapsed, it is found directly behind the cervix 
uteri in the most dependent portion of the sac of Douglas. So ex- 
actly central is the position of the ovary that in most of my cases I 
could not tell whether it was the right or left ovary, and could only 
settle that question by finding the other one in its normal position. 
If the prolapsus is incomplete the ovary is found on one side of 
the cervix uteri, usually at a point a little above the junction of the 
body and cervix. In complete prolapsus the ovary feels not unlike 
the fundus uteri, and gives the impression of retroflexion of the 
uterus. The distinction can be made by the peculiar sensitiveness 
of the ovary to pressure, and by the fact that the finger can usually 
be insinuated between the uterus and the ovary. Should there still 
be a doubt, the question can be solved by passing the sound which 
will exclude flexion of the uterus. 

There is another condition which proves to be somewhat puz- 
zling, that is complete prolapsus of the ovary with the retro verted 
uterus lying directly upon and above it. In one such case which 
came under my care, I was able to make out the true state of affairs 
by passing the sound, and while it was in place raising the uterus 
far enough to lift it off the ovary, so that by the touch I could dis- 
tinguish the one from the other. 

Prognosis. — The prospect of permanently overcoming the dis- 
placement depends upon the length of time that the malposition has 
existed; upon the condition of the ovar}^, whether normal or diseased, 
and whether there are other complications, such as adhesions, retro- 
version, or retroflexion of the uterus. In recent uncomplicated cases 



DISEASES OF THE OVARIES. 471 

a permanent restoration may be effected if the patient can be kept 
under treatment for a sufficient length of time. In complicated 
eases all ordinary local treatment fails. It is then that the question 
of advisability of removing the ovaries comes up for consideration. 
Should the patient be near the menopause, she may be carried along 
past that change, and the recovery may come. In younger subjects 
the ovaries should be removed if all else fails to give relief. 

Causation. — The following are the causes of displacement of the 
ovaries, named, as far as my knowledge guides me, in the order of 
their frequency. 

Subinvolution ; enlargement of the ovaries from hypersemia, 
ovaritis, or other affections ; displacements of the uterus ; congenital 
malposition from derangements of development and growth. In 
regard to subinvolution, it may be well to call to mind the fact that 
in the puerperal state, the ovaries — especially the left one — are very 
large, nearly twice as large as at other times, and if care is not taken 
to secure complete involution after confinement the heavy ovaries 
will naturally descend, and by making traction upon the peritonaeum 
and ligaments will overstretch them. I believe also that subinvolu- 
tion of the broad ligaments will permit the ovaries to descend into 
the pelvis when they are not much enlarged. At any rate, I have 
found the ovaries prolapsed when they were not large, but when the 
broad ligaments were long and relaxed, a condition which followed 
confinement. In regard to the other causes of prolapsus of the ova- 
ries they are suflftciently clear to warrant my saying nothing more 
about them. 

Treaimient. — The first thing to do is to ascertain if the displaced 
ovary is movable and can be raised up to its normal position. If 
that can not be accomplished, owing to adhesions, then there is little 
to be hoped for from treatment. When the ovary is movable it can 
be placed in position by putting the patient in the knee-chest posi- 
tion, using a Sims's speculum, and then making upward pressure 
through the vaginal wall with a sponge held in a sponge-holder. In 
short, the same method is employed as in restoring a retro verted 
uterus. To keep the ovary in place the cotton tampon is the best. 
It should be removed every forty-eight hours, and two or three times 
daily the patient should take the knee-chest position if she is able to 
be up from bed during the day. The use of the tampon in this way 
takes much time, and I have taught several of my nurses to use it 
with very satisfactory results. 

Prof. Goodell recommended that the patient should separate the 
labia while in the knee-chest position, in order to distend the vagina 



472 DISEASES OF WOMEN". 

with air, and Dr. C. F. Campbell uses for the same purpose a glass 
tube open at both ends, which is introduced into the vagina before 
the patient takes the knee-chest position. I have tried both of these 
methods, but have given them up for two reasons : In the first 
place, because distention of the vagina is unnecessary. In the knee- 
chest position the pelvic organs will rise high enough and assume 
their normal position as well with the vagina closed as open ; of 
this, any one can satisfy one's self by making an examination before 
and after this position has been assumed. In the second place, I 
find that the less local treatment patients give themselves the better 
it is for them. The first medical book of any kind that I ever read 
was entitled " Every Man his own Physician," by one Dr. Buchan. 
It was a very useless production, but had the good effect of preju- 
dicing me against making every woman her own gynecologist. I 
much prefer the tampon and the knee-chest position. If there is 
retroversion or flexion of the uterus present at the same time, that 
organ should be replaced each time that the tampon is changed. 
When considerable has been gained by the above treatment, and the 
ovaries and uterus are replaced sufficiently to get a pessary under 
them, one should be introdaced. The form of instrument and the 
method of using it are the same as in retroversion of the uterus and 
need not be detailed here. I have tried the special forms of pessa- 
ries recommended by Tait, Mimde, and others, but have not been 
able to do as well with them as with the instrument which I employ 
in retroversion of the uterus. In a few cases I have succeeded in forc- 
ing the uterus, ovaries, and vaginal wall upward and backward, thus 
giving some relief for a time, but the traction upon the vaginal wall 
causes stretching, and when the pessary is removed the displacement 
returns to a degree as great if not greater than before. 

While this local treatment is employed every effort should be 
made to improve the patient's general health. Rest should be in- 
sisted upon, in the recumbent position at first, and as the case 
progresses favorably, short stages of exercise may be permitted. 
Throughout the whole treatment all sexual relations should be pro- 
scribed. 

When all other treatment fails, and the patient still remains a use- 
less invalid, the ovaries should be removed, or attached to the upper 
margin of the broad ligament or abdominal waU. 



CHAPTER XXYL 

NEOPLASMS OF THE OVARIES. 

I HAVE made a classification of the morbid growths of the ova- 
ries which I believe will best serve the practical requirements of 
the gynecologist, although it may not be quite in keeping with the 
arrangement of the subject usually found in the text-books. In fact, 
it would be hardly possible to make any classification w^hich would 
agree with all of the many authorities on the subject. 'Nor would it 
be possible to present an argument in favor of the classification which 
I have adopted without either taking more time and space than I 
can afford, or else omitting to mention the statements of many 
whose views are well worthy of consideration. I am obliged to sim- 
ply state in brief that which to my mind appears necessary to the 
student and practitioner. 

The first class is made up wholly of cystic tumors, with a single 
exception, to which I shall refer later, and of these there are two 
varieties — follicular cysts and adenoid cystomata. Both of these va- 
rieties occur in a simple and in a compound form. Thus we may 
have (a) simple unilocular cystoma, and (h) simple follicular cysts, or 
of the compound form we may have (c), multij^le follicular cysts, 
(d) multiple cystoma, {e) multilocular cystoma, (/) papillary cys- 
toma, and (g) dermoid cystoma ; and also (A) fibrous, and (t) cysto- 
fibroma. 

The second class, which many speak of as malignant growths, 
contains four varieties : (a) carcinoma, (h) cysto-carcinoma, {c) sai*- 
coma, and {d) cysto-sarcoma. 

Classification. — These morbid growths I have arranged in two 
classes : 

1. Those that are most frequently seen in practice, and that are 
to some extent amenable to surgical treatment. 

2. Those that are rarely met with, and that resist all kinds of sur- 
gical treatment, and tend by their very nature to a fatal termination. 



474 DISEASES OF WOMEN". 

Tumors of the first class are spoken of bj some authorities as 
benign, while the term malignant is applied to those which I have 
placed in my second class. 

OVABIAN CYSTS. 

Patliology. — The kind of ovarian neoplasm most frequently seen 
is the cystic tumor, or ovarian cyst, as it is generally called. 

The development and growth of ovarian cysts and cystomata 
vary in different cases in many respects, and still there is a certain 
sameness in the majority. The growth of these has been divided 
into three stages, the division being based upon certain features of the 
natural history of these neoplasms rather than upon any changes in 
their pathology. In the first stage the tumor is small, and confined 
to the pelvic cavity. This stage begins with the formation of the 
morbid growth and ends when it is large enough to rise out of the 
pelvis into the abdominal cavity. The duration of this stage can not 
be estimated, because there is no way by which the morbid growth 
can be detected until it has attained considerable size. In many 
cases an ovarian tumor gives rise to no marked disturbance, and 
therefore remains unnoticed until it has reached the second stage. 
This stage begins when the tumor rises up into the abdomen, 
and ends when the patient's general health begins to deteriorate. 
These constitutional effects of the morbid growth mark the begin- 
ning of the third stage. The first stage often passes by witliout the 
presence of any abnormality being suspected. It is only when press- 
ure upon the pelvic organs or when some inflammatory action in 
the ovary or pelvic peritonaeum occurs, that there is any likelihood 
of the affection being discovered. There is reason to believe, from 
the cases w^hich have been watched, that the growth is steadily pro- 
gressive as it is in other neoplasms. The natural history of non- 
malignant tumors is that they go on gradually increasing until they 
attain a size sufficient to destroy life. This requires from two to 
three years on the average, but there is a great variation in time 
in different cases. There are periods of cessation of growth followed 
by rapid increase in size. These alternations of increase and pas- 
siveness may occur repeatedly, or the progress may be continuous. 

In the third stage the general health of the patient begins to 
suffer. There is usually loss of flesh, and the face shows evidence 
of ill-health. A certain facial expression has been described as the 
facies ovarii, but this is difficult to describe or recognize. It may 
be said to be an emaciated, careworn appearance, without the bronze 
hue of the cachectic state. This malnutrition is due at first to ex- 



NEOPLASMS OF THE 0VAEIE8. 475 

haustion from the growth of the tumor, and finally to pressure 
upon the neighboring organs. The functions of the abdominal and 
thoracic organs become deranged from pressure, and cause exhaus- 
tion and death by slow degrees. 

Death sometimes comes suddenly from asphyxia due to pressure 
upon the thoracic organs. Sometimes peritonitis is the immediate 
cause of death. In the majority of cases that are permitted to run 
their course, the patient is slowly crowded out of existence by the 
enormous size of the tumor. Fortunately, there are few cases in 
this age that are permitted to be lost in this way. 

Toward the end of the third stage oedema of the limbs generally 
appears. This is more likely to occur if the patient is unable to lie 
down in bed. 

The simple cyst is the most easily comprehended, and will there- 
fore be first described. It is composed of the cyst proper and the 
pedicle. The cyst is made up of the cyst- wall and the contained fluid. 

The pedicle is usually composed of the ovarian ligament. Fallo- 
pian tube, and part of the broad ligament. The cyst and the pedi- 
cle have one covering in common — namely, the peritongeum. 

Simple Cysts. — The simple cyst is usually globular in form, and 
its walls are generally of uniform thickness. The size varies in dif- 
ferent cases from a microscopic object to one weighing one hundred 
pounds or more, according to the age of the growth. By the term 
simple or unilocular cyst it is not intended to imply that the tumor is 
absolutely composed of a single cyst, since it is believed by the best 
authorities that ovarian cysts are always multiple, but the term is 
applied to that variety of cyst which in its gross anatomy appears 
to be single, and which can be managed by the surgeon as a single 
cyst. The one sac or cyst is large and appears to be single, but on 
close inspection minute cysts are generally found in varying num- 
bers in the major cyst, or in that portion of it which joins the 
pedicle. 

Compound Cysts. — These are distinguished froto the simple vari- 
ety by being multiple — that is, the whole tumor or mass is formed 
by the aggregation of several simple cysts, each being large enough 
to be easily recognized. The usual form of this multiple variety of 
cyst is that in which one of the divisions or cysts is much larger 
than all the others taken together. The greater contains the lesser 
ones, which are usually formed in a cluster attached to one side of 
the major cyst, near the pedicle. 

It will be observed that the difference between the single and 
multiple cyst is that in the latter there are a numl)er of well-defined 



476 



DISEASES OF WOMEN. 




Fig, 190. — Left ovary distended into one large cyst, into the interior of which smaller 

cysts project (Farre). 

cjsts, one large one and a number of others varying in size from 
that of a man's head to a small hazel-nut, while the former is com- 
posed of one cyst with a few almost imperceptible cysts. 

Multilocular Cysts. — These are so called because the sacs or cysts, 

which in the aggregate make up 
the whole tumor, are larger in 
size and more nearly equal. The 
general appearance of the mass 
is of one large cyst-wall contain- 
ing a number of cysts which 
vary in size. Sometimes one or 
more of the cysts is much larger 
than the others. In other cases 
there are several cysts varying 
in size from that of a human 
head to that of an orange, with 
a large number of smaller cysts. 
From the general appearance 
and arrangement it would ap- 
pear that the cysts included 
within the major cyst-wall had 
been developed from the inner 
cyst-wall, and others still had 
been developed from the second 
,.^ . crop by a process of endogenous 

-Compound and prohterating cyst i . /. . nm . 

(Farre). proliferation, i ins may or may 




Fig. 191. 



NEOPLASMS OF THE OVARIES. 



477 



not be the fact, but it is more likely that the ovary from which the 
morbid growth is developed contains a number of germs included 
in the structure of the ovary which forms the cyst-wall, and that 
they all grew from similar germs and are aggregations rather than 
proliferations. The gross appearance of such tumors is the chief 
point of interest to the surgeon, viz., that one cyst-wall contains 
within it a number of cysts ; usually, there are one or two large 
cysts^ a larger number of medium size, and a very great number of 
small ones, varying in size and united to each other. The cavities of 
these cysts rarely communicate with each other. Occasionally a cyst 
is found the cavity of which is divided by septa, but associated with 
such there is always a number of independent cysts. 




Fig. 192. — Multilocular cyst (Hooper). 

I have, on one occasion, seen two cystomata growing from an 
ovary, one on each side, the whole resembling somewhat a dumb- 
bell in shape. 

Complex Cystoma. — These tumors are called complex or mixed 
because they differ from those already described by the addition to 
the cyst structures of other pathological elements, or else there is a 
marked development of some special portion of the cyst elements — 
the cyst- wall, for example. 

These peculiar portions of the growth may consist of a hyper- 
trophic increase in tlie tissues of an ovarian follicle, or of hypertrophy 
of the stroma of the ovary, infiltrated with serum or other morbid 
fluids. Proliferation of the fibrous tissue may give rise to one or 
more fibrous masses connected with the cyst. The cyst- wall may be 
greatly thickened generally, or in certain portions, from hypertrophy 
of either its inner or middle laver. The inner surface or liniiio^ 
membrane of a cyst may develop new structures or proliferations. 



478 



DISEASES OF WOMEN". 



Again, the contents of a cyst may be of a character entirely differ- 
ent from the ordinary fluid found in simple or compound cystic 
tumors. In this way the following complex tumors are formed : 

Papillary Cysts. — In this form of cyst the connective tissue of 
the cyst-wall undergoes hyperplasia in certain places, and the growth 




Fig. 193. — Papillary cystoma of ovary showing proliferation (Winckcl). 

of the tissue pushes the lining membrane of the cyst before it, and 
in that way a great number of papillae are found projecting into the 
major cyst and covering, it may be, the whole internal surface of 
the sac. The papillae are sometimes very vascular, and are covered 
with columnar epithelium. 

Dermoid Cysts. — The characteristics of these tumors differ very 
markedly from those already described. The genesis of this cyst is 




Fig. 194. — Dermoid cyst of ovary, filled with hair and tallow-like masses (Winekel). 

peculiar, and this may account for the fact that its contents are made 
up of specimens of most of the tissues of the body ; hair, bone, teeth, 
and adipose tissue are usually in the greatest abundance. 



NEOPLASMS OF THE OVARIES. 



4Y9 



Cysto-Fibroma, — In this form of tumor the fibrous portions 
closely resemble, in structure, fibrous tumors of the uterus. They 
do not differ in their outward appearance from the ordinary simple 
cyst, but the touch shows one part of the mass to be solid and the 
other fluid. These morbid growths are quite rare. I have met with 
but two in my own practice. 



FIBROMA OF THE OVARIES. 



This rare form of ovarian tumor I have classed with the cys- 
tomata, not because it presents any features in common wdth the 
class, but because it calls for surgical interference and does not in 
any way belong to the second class, having no inherent tendency to 



Hintert Utertcsvmn^. 




Ei.erstodCs. 



Ohe^tdch^.d.lE. ^c/mimckJ^d^iUn. 



Fig. 195. — Fibroma affecting both ovaries (Winckel). 

prove fatal except by indirect effects. It is rare, and hence not of 
sufficient importance to demand a separate class for itself alone. In 
describing this form of neoplasm I may say that it is like the cysto- 
fibroma, minus the cyst or cysts. The composition of the growth is 
similar to that of the fibroid tumors of the uterus. That the fibroma 
of the ovary is very closely related to the cysto-fibroma, is further 
shown from the fact that so-called fibromata have been found with 
small cysts. In the one the cyst element predominates, while in the 
other the solid or fibrous element is the principal or only one found. 
32 



480 DISEASES OF WOMEN. 

Cyst-WalL — The walls of the cysts of ovarian tumors are, as a 
rule, nearly all the same. For convenience of description and for 
the purposes of the surgeon the wall is divided into three layers. 
The external is a serous membrane corresponding to the peritonaeum, 
which it is in fact. The middle coat is areolar tissue, and contains 
the main blood-vessels of the cyst. The internal layer is like the 
external, so far as its fibrous elements are concerned, but it is really 
a mucous membrane. It is less uniform than the other layers in 
appearance, and usually contains small cysts in process of develop- 
ment, or follicles which have undergone degeneration. Papillge are 
often found developed on this layer, as already stated. While this 
in a general way describes the cyst- walls, they are subject to certain 
modifications, as follows : The middle layer, which is well defined at 
the base of the tumor, contains the large vessels, and is easily sepa- 
rated from the peritoneal layer. It becomes thinner the farther it 
departs from the pedicle, and when it reaches about the middle of 
the tumor there are only two layers easily distinguished, while at 
the summit there is only one that can be made out by ordinary dis- 
section. 

While the middle layer diminishes gradually as it gets farther 
and farther away from the base and finally disappears, the internal 
and external layers come together and are united, and increase in 
thickness so that the cyst- wall becomes a fibrous homogeneous mem- 
brane. Some authors have made more minute subdivisions of the 
layers of the cyst-wall, but that I look upon as a super-refinement in 
dissection which has no value in this connection. 

The outer and inner coats are often modified in appearance and 
character. The external layer is changed in places by circumscribed 
peritonitis, or by great vascularity, and the internal coat is often 
changed by inflammatory action, degeneration, or hyperplasia. 

The appearance of the outer coat has a special interest for the 
surgeon. To be able to recognize the cyst-wall when one comes to 
it in operating is very important. Many times, in simple uncompli- 
cated cases, the cyst-w^all is smooth, of a whitish color, slightly tinged 
with a pinkish, pearly tint which resembles the peritonaeum, every- 
where covering the abdominal viscera, and yet easily distinguished. 
When there has been peritonitis, the cyst-wall becomes covered with 
lymph or adhesions, and so changed in appearance that it is difficult 
to recognize it when it is reached, owing to the products of inflam- 
mation. The vascularity of the outer coat of the cyst varies greatly. 
Sometimes the whole surface presents a fine network of vessels all 
over the parts that are seen ; in other cases the vascularity is exag* 



NEOPLASMS OF THE OVARIES. 481 

gerated in patches. This great vascularity, when it occurs with- 
out preceding evidence of inflammation, makes a marked contrast 
between the cyst and the abdominal viscera, which enables one to 
promptly distinguish the one from the other. In a few tumors, all 
of them occurring in oldish patients, I have found large portions of 
the cyst-wall of a pale, grayish-white color, without any recognizable 
vascularity. This made the cyst very peculiar in appearance and 
easily recognized. This rare and peculiar color is caused by com- 
mencing necrosis. 

Contents of Ovarian Cysts. — The contents of the simplest variety 
of cyst are a serous fluid of a lemon or amber color, but subject to 
marked variation in different cases. The character of the fluid is 
modified by the size of the cyst, the length of time it has existed, 
arid whether the cyst has been tapped ; under these modifying influ- 
ences the fluid may be colorless, or chocolate-colored from the pres- 
ence of blood in varying quantity, or it may be of a greenish-yellow 
color, from the presence of pus produced by inflammation of the 
cyst. Shreds and flakes of whitish lymph are sometimes found with 
the pus when there has been inflammation. Occasionally the fluid 
is viscid. 

It generally contains albumen or paralbumen, and sometimes 
crystals of cholesterine are found in it. The contents of the multi- 
locular cysts resemble those just described, presenting the same dif- 
ferences in different patients. Usually the fluid is more viscid or 
gelatinous, sometimes quite thick, so that it escapes with difficulty. 
In one case I found the cyst contents exactly like jelly, but different 
in character in this, that jelly is friable, but this material was ex- 
ceedingly tenacious, so that it could not be pressed out of the sac, 
and was even pulled out with the hand with great difficulty. The 
fluid in the several cysts of a multilocular tumor is not always the 
same. It often differs in color and consistency in the different 
divisions of the tumor. In addition to the albumen, blood, choles- 
terine, pus, and lymph, which may be present in the fluid of ovarian 
cysts, there are other chemical and anatomical elements found which 
are of interest. 

The contents of ovarian cysts have been most thoroughly investi- 
gated as to their chemical composition by Eichwald. As has already 
been stated, they may be as fluid as serum, or, as is more often the 
case, viscid sometimes to such a degree as to be gelatinous in con- 
sistency. The specific gravity may be as low as 1007, or as high as 
1020. There are two distinct classes of elements which occur in 
the contents of these cysts : the one mucous in its nature, which 



482 DISEASES OF "WOMEX. 

predominates in the younger cysts ; tlie other albuminous, which is 
characteristic of the large and older colloid cysts. The colloid sub- 
stance is regarded as a modified mucine formed from the substance 
of the colloid bodies and the parenchyma of the cells of the ovaries. 
Colloid degeneration is therefore but another name for mucous 
metamorphosis. The first or mucine class consists of four ele- 
ments : the substance . of the colloid corpuscles, mucines, colloid 
substance, and muco-peptone. These are distinguished by their 
solubility in water, and by various reactions which need not be 
mentioned here. 

The second or albuminous class is characterized by the presence 
in the contents of the cysts of free albumen and the albuminate of 
soda. In colloid tumors the free albumen becomes albuminoid pep- 
tone, while the albuminate undergoes no change. . The conversion 
of free albumen takes place slowly ; it first becomes paralbumen, 
then metal bu men. These are not fixed bodies, but pass on to the 
condition of peptone. Thus, the albuminous elements which are 
found in this albuminous class are albuminous paralbumen, metalbu- 
men, and albuminoid peptone. In a chemical analysis of the con- 
tents of a cyst, Eichwald found the following to be its composition : 

Water 931.96 

Organic substances. 59. Y7 

Potass, sulph .08 

'' chlor 59 

Sod. nit 6.29 

'' phosph 16 

" carb 38 

Salts insoluble in water .74 

Loss 03 

1000.00 

MICROSCOPIC CONTENTS OF OVARIAN CYSTS. 

Under the microscope the contents of different cysts present very 
different appearances. The cell elements abound in those which are 
colloid in their nature, while those which are serous are very defi- 
cient in this respect. Eichwald, in one of the colloid cysts, found 
so large an amount of corpuscular elements that he was unable to 
examine it satisfactorily with the microscope until he had diluted it 
with water. When thus treated he found fatty elements, round and 
serrated cells, large colloid cells, round cells resembling those de- 
scribed by Lebert as pyoid bodies, and by Henle as exudation corpus- 



NEOPLASMS OF THE OVARIES. 483 

cles ; globular aggregations of various sizes, scales of epitlielium, 
crystals of cliolesterine, and brown pigment were also found. As a 
rule, the morphological elements found in the fluid of ovarian cysts 
are granular cells, free granules, small oil-globules, epithelial cells, 
blood-corpuscles, Gluge's corpuscles, and pus cells. From time to 
time various cells have been described as characteristic of the ovarian 
cyst. Among others, Drysdale has described such a cell, which he 
speaks of as "' the ovarian granular cell," and which he regards as 
pathognomonic of ovarian disease. His claim to the discovery of 
this cell is thus put : " I claim, then, that a granular cell has been 
discovered by me in ovarian fluid, which differs in its behavior with 
acetic acid and ether from any other known granular cell found in 
the abdominal cavity, and which, by means of these reagents, can be 
readily recognized as the cell that has been described ; and, further, 
that by the use of the microscope, assisted by these tests, we may 
distinguish the fluid from ovarian cysts from all other abdominal 
dropsical fluids." 

This " ovarian granular cell " of Drysdale is generally round, 
but sometimes oval, is very delicate and transparent, and contains a 
number of fine granules, but no nucleus. The size of the cell varies 
from -g-.oVo ^^^^^ *^ F-oVo i^ch. When acetic acid is brought in 
contact with this cell it becomes more transparent, and its granules 
appear more distinct. On the other hand, when thus treated with 
acetic acid it becomes larger, and from one to four nuclei appear. 
It is distinguished from Gluge's inflammation corpuscle by the fact 
that, when ether is added, the ovarian cell is unaffected — at most, 
has its granules made paler ; while Gluge's corpuscle loses its granular 
appearance, and sometimes entirely disappears through a solution of 
its contents by the ether. In reference to this subject it may be said 
that the views of Drysdale deserve the most careful consideration, 
but I am not as yet satisfied in my own mind that this corpuscle is 
pathognomonic of ovarian disease, nor indeed that the diagnosis can 
be positively made by either chemical or microscopical analysis. 

Complications. — There are certain pathological changes which 
occasionally occur during the progress of an ovarian tumor which 
may be considered as complications of the original affection. The 
presence of an ovarian tumor tends to excite circumscribed inflam- 
mation of the peritonaeum, which gives rise to adhesions of the cyst 
or tumor to the pelvic or abdominal viscera. This is the most fre- 
quent complication, and one which is of exceeding interest to the 
surgeon. The location, extent, and firmness of the adhesions differ 
greatly according to the duration, size, and character of the cyst or 



484: DISEASES OF WOMEN. 

tumor. It is also possible that the state of the patient's constitution 
and general health may have some influence in determining the 
development of inflammatory adhesions. In regard to the efiect 
which the nature of the tumor has upon the occurrence of adhesions 
my observations lead me to believe that malignant growths and 
those that are mixed — that is, in part benign and in part malignant 
— are most frequently found to have adhesions. It is also a ques- 
tion whether the adhesions found by some of these neoplasms result 
in all cases from peritoneal inflammation. In some cases that I 
have seen it appeared to me that the ovarian tumor became attached 
to the viscera in contact with it by an extension of the ovarian dis- 
ease. It may be that in such cases the malignant disease may have 
begun in other organs and tissues as well as in the ovary, and that 
the diseased parts became united without intervening products of 
inflammation ; occasionally adhesions occur where the tumor is small, 
and then they are found in the pelvis or in relation with the lower 
intestines. TVhen they take place after the tumor is large enough 
to distend the abdominal walls they are found higher up. Then the 
tumor may be adherent to the abdominal wall, omentum, stomach, 
loin, diapliragm, or to the lumbar region. Such extensive adhesions 
are rather rare, still they occur sufiiciently often to be of the great- 
est interest to the surgeon. These adhesions sometimes disjDlace the 
pelvic organs and derange their functions. When a small tumor 
becomes adherent to the uterus or bladder it will carry these organs 
up out of place when it grows larger and rises up into the abdominal 
cavity. 

Obstruction of the intestines may be caused by the traction of 
adhesions and also by the pressure of a very large tumor. Occasion- 
ally a small tumor in the pelvis may make pressure upon the rectum 
sufiicient to obstruct the action of the bowels, but that is rather rare, 
unless the tumor is so firmly fixed by adhesion that it can not be dis- 
lodged. Rotation of the tumor upon its axis occasionally takes place. 
This produces twisting of the pedicle and partial or complete stran- 
gulation of the blood-vessels and tissues of the pedicles. The result 
is that the blood can not return from the tumor, and hence the ves- 
sels become overdistended and sometimes rupture follows. The 
bleeding into the cyst suddenly distends it and causes shock. Some- 
times the cyst ruptures under the pressure of the hsemorrhage with- 
in it and death may take place. Cases have been known of haemor- 
rhage into the cyst which have proved fatal from shock and loss of 
blood without the cyst bursting. Should the patient withstand the 
shock and haemorrhage, peritonitis and cystitis are likely to occur. 



NEOPLASMS OF THE OVARIES. 485 

Death takes place as a rule, if the twisting of the pedicle is suffi- 
cient to completely arrest the circulation. This proves fatal unless 
the tumor is removed. If the twisting is not sufficiently marked to 
arrest the nutrition of the tumor suddenly and completely atrophy 
may take place instead of gangrene or necrosis. Spontaneous cure 
has taken place in this way, the tumor shriveling up and disappear- 
ing. Some very curious things have happened from tv/isting of the 
pedicle. Atrophy has taken place so perfectly that the pedicle has 
been severed, the tumor becoming entirely free from all attach- 
ments. 

More strange things still have happened. The tumor has be- 
come adherent to some part of the abdominal viscera and subse- 
quently the pedicle has become separated from the tumor by a pro- 
cess of slow atrophy. While the separation of the pedicle is slowly 
disappearing the vascularity increases at the point of adhesion, and 
the tumor derives its nourishment from its new attachment. This 
has been described as transplantation, a term which clearly indicates 
the process which takes place. 

Dragging of the Pedicle gives results similar to twisting. This 
dragging is produced usually when pregnancy occurs during the ex- 
istence of an ovarian tumor. The uterus growing faster than the 
pedicle pushes the tumor upward and makes strong and continuous 
traction upon the pedicle and obstructs the vessels. Again, if the 
ovary is adherent in the pelvis, and the pregnant uterus ascends, 
traction will be made sufficient to damage the nutrition of the ovary 
and any cyst that may exist there. There is another way in which 
traction of the pedicle may occur. A cyst or tumor may be carried 
high up in the abdomen with the pregnant uterus, and become 
adherent at its higher part, and when the uterus descends after 
delivery the pedicle may become stretched. It is presumed that 
cystic tumors may become atrophied and a spontaneous recovery oc- 
cur. This belief is based upon the fact that in old women the ova- 
ries have been found to contain shrunken cysts imbedded in very 
hard, thickened stroma and it is believed that this condition is the 
result of atrophy by cystic tumors. There is no absolute proof that 
absorption of the fluid and shriveling of the cyst-w^all occurs except 
by obstruction of the blood-vessels in the pedicle as akeady de- 
scribed. 

Rupture and Perforation of Ovarian Cysts. — Kupture may occur as 
the result of overdistention of the cyst-wall from rapid accumula- 
tion of fluid in the cyst, or from injuries such as direct blows or 
concussions from falling or sudden exertion. The bursting of a 



486 DISEASES OF WOMEN". 

cyst may cause death, or the opening may be closed by inflamma- 
tory exudation and the cyst refill. It has also been claimed that the 
cyst may disappear, and the patient recover. When this spontane- 
ous recovery occurs after the bursting of a cyst, there is always 
room for doubt about its being an ovarian cyst. For the present 
it must remain an open question whether ovarian cysts ever disap- 
pear in this way. It is, however, well known that cysts of the 
ovary frequently burst aud empty their contents into the abdominal 
cavity. The results of this differ greatly ; sometimes there is not 
much trouble if the fluid is clear and non-irritating ; in other cases 
death is caused in a short time by shock, or peritonitis may follow 
and cause death or terminate in closing the opening in the cyst and 
forming extensive adhesions of the cyst- and abdominal-walls and 
viscera. In those cases which recover from the shock of rupture 
and the subsequent peritonitis and the cysts reflll there are always 
extensive adhesions found. 

Perforation differs from rupture in being a slow process and in 
the fact that the opening is frequently into the adjoining viscera of 
the abdomen or pelvis. There are two ways in which perforations 
occur ; the one by thinning of the cyst-wall from pressure, either 
from within the cyst or from without at a given point, and the other 
and most frequent by suppuration or ulceration. Perforation occur- 
ring in either way may open into the peritonaeum, but in case the 
opening is the result of suppuration it may be into some of the 
neighboring organs. In some cases the perforation is very small 
and the opening is closed by exudations which also form adhesions 
to the neighboring organs. This fact has led to the belief that 
many of the adhesions found are the result of these small perfora- 
tions which admit of a limited escape of the cyst fluid. Should the 
perforation be large a free escape of the fluid may take place, and 
the result would be the same as in case of rupture. When the per- 
foration is into the intestine, the contents of the sac may be wholly 
emptied, but this form of perforation is rare. 

Another rare form of perforation has been seen in which a 
communication between an ovarian cyst was formed by ulceration 
extending from the intestine and opening into the cyst. 

Ovarian Cystitis. — Inflammation of the interior of the cyst occurs 
occasionally and is a serious complication. In multiple and multi- 
locular cysts the inflammation is usually limited to one or more of 
the cysts, the others in the tumor remaining in their original condi- 
tion. The inflammation is of a low form in most cases and ends in 
suppuration ; in others there is a mixture of pus with shreds and 



NEOPLASMS OF THE OVARIES. 487 

flakes of lymph. The original fluid in the cyst is supplanted to a 
large extent by these products of inflammation. 

This was well illustrated in a case of a monocyst which came un- 
der my care years ago. I tapped the cyst, and withdrew a half a 
pint of clear fluid, inflammation followed, and the cyst slowly flUed 
up but did not increase beyond its original size. It became adher- 
ent to the abdominal wall and finally opened externally, and it was 
then found to be filled with pus. 

In another case a hypodermic syringe full of clear fluid was 
drawn 0"ff from the major cyst of an ovarian tumor, and then inflam- 
mation followed, and the patient was subsequently brought to me 
for operation. I found pus and lymph in the cyst, but the most of 
the original clear fluid had disappeared. 

Abdominal dropsy is still another complication which may occur. 
There is in many cases a little free fluid in the peritoneal cavity 
which is not of special interest, but in other cases the quantity of 
fluid is such that it may in bulk exceed that of the ovarian tumor. 
This is more likely to occur in malignant growths and in papillary 
ovarian cysts. This will be referred to again while discussing diag- 
nosis and treatment. 

There are many local and constitutional conditions which may 
be found accompanying ovarian tumors, but those complications 
which can be rationally considered as resulting from the affection of 
the ovary have been mentioned. 



CHAPTER XXYIL 

CYSTIC TUMOES OF THE OVARIES — SYIMPTOMATOLOGT AND PHYSICAL 

SIGNS. 

The most peculiar feature in the clinical history of this variety 
of ovarian tumor is the fact that subjective symptoms are often ab- 
sent. Cases are sometimes seen in which the patient is unconscious 
of anything being wrong until the tumor becomes noticeable by 
the increased size of the abdomen. It is equally strange that the 
tumor is often unobserved by the patient until it has attained a con- 
siderable size. But, while cases occur without noticeable symptoms, 
the majority of patients suffer from some pain and discomfort, and 
at the same time there is more or less derangement of the function 
of the ovaries, and occasionally some disturbance of neighboring 
organs. The symptoms differ in the different stages of the growth 
of the tumor. I will, therefore, take up the three stages in order. 
In the first stage, while the tumor still occupies the pelvic cavity, 
the patient may have a feehng of fullness in the pelvis, and pos- 
sibly some pelvic tenesmus on standing or walking; pain is also 
present in the affected side. The severity of the pain differs great- 
ly in different cases. In some it is onl}^ sufficient to attract the 
attention of the patient at times, but is not acute enough to pre- 
vent her from performing her ordinary duties. In others it is 
quite severe, and accompanied with well-defined tenderness, dis- 
abling the patient to some extent. These symptoms may or may 
not be continuous. The pain may be at times very slight for days 
or weeks, then increase, and again subside, and yet at no time be 
sufficiently marked to cause the sufferer to seek advice, and its ex- 
istence is only brought out by interrogation at a more advanced 
stage of the affection. When the pain is acute and sufficient to dis- 
able the patient, there is usually some local inflammation to account 
for it. When such is the case, there is ordinarily some constitutional 
disturbance indicative of the local affection. In quite a number of 



CYSTIC TUMORS OF THE OVARIES. 489 

cases there is pain for a few days at or just before the menstrnal 
period, or it may be midway between the periods. 

The pain is in the affected ovary, and is often of that character 
which is called ovarian. It has been supposed that this kind of in- 
termittent pain is due to ovulation, occurring in the morbid ovary. 
When the pain occurs in the intra-menstrual period, it is presumed 
to be caused by some trouble during the maturation of the ovule ; 
and, when it comes on about the menstrual period, it is due to the 
process of rupture of the Graafian vesicle. Menstruation is fre- 
quently deranged, but not always. While one ovary is affected, 
the other may be normal, and, so far as the ovaries influence men- 
struation, there is no change, and the uterine function goes on in 
the usual way. This is sometimes the case when both ovaries are 
affected. It would appear that, while a part of the ovaries is mor- 
bid, there still remains enough that is normal to perform the func- 
tion and maintain the ovarian influence upon menstruation. It 
frequently happens, however, that menstruation is deranged dur- 
ing the existence of ovarian tumors. As already stated, there may 
be pain at the menstrual period, which is easily mistaken for dys- 
menorrhoea. Irregularity or suppression of the menses is, I believe, 
the most common derangement. Profuse and too frequent men- 
struation occasionally occurs, but either of these derangements may 
be due to some constitutional condition or some uterine affection, 
which may accompany the ovarian tumor. When the ovarian tumor 
attains considerable size, and is yet not large enough to rise out of 
the pelvis, it may cause displacement of the uterus or bladder, and 
give rise to symptoms peculiar to this displacement. It is not often 
that these cause sufficient suffering to lead the patient to seek reKef 
at the hands of the gynecologist. When the left ovary is the sub- 
ject of the morbid growth, there is, in some cases, slight obstruction 
of the rectum, which causes disturbance in the action of the bowels. 

The important fact still remains that, in the first stage of cystic 
tumors of the ovaries that are uncomplicated, the symptoms are often 
so mild that the patient may not come under the care of the medical 
attendant, and, if she does, the symptoms do not afford any reliable 
guide to the nature of the affection. 

In short, there is nothing diagnostic in the symptomatology of 
this stage of ovarian tumors. 

In the second stage, an enlargement of the abdomen is noticed 
sooner or later by the patient. If the pedicle is short, the enlarg-e- 
ment may be on one side ; usually it is central, or nearly so, when 
fii'st noticed. Here, again, there are no other very well-marked 



490 DISEASES OF WOMEK 

symptoms. As the tumor increases, the weight and pressure cause 
discomfort. This is likely to be felt earlier in those who have not 
borne children than in those who have. In such patients the ab- 
dominal muscles do not yield so readily to accommodate the tumor. 
Slight pains recurring at intervals and tenderness are common symp- 
toms, and are usually due to tension of the cystic walls from increase 
of the contents. When such pains occur, the tension of the cyst is 
marked, and the pain subsides when the cyst becomes flaccid. If 
inflammation of the cyst or portions of the peritonaeum occurs, there 
are, in addition to pain and tenderness, some constitutional symp- 
toms, such as fever, rigors, and, if the inflammation is extensive, 
deranged digestion, loss of flesh, and hectic may follow. Theso 
symptoms are relied upon as indicating inflammation, which will 
produce adhesions, especially if the peritonaeum is involved ; but 
it should be borne in mind that quite extensive adhesions may take 
place without their having been at any time well-defined symptoms 
of circumscribed peritonitis. Ordinarily, these are all the symptoms 
manifested in the second stage. 

In the third stage, when the tumor begins to make strong press- 
ure upon the d liferent viscera, another class of symptoms appears. 
These were hinted at while discussing the growth of ovarian tumors. 
Deranged digestion and impaired micturition, difiicult breathing, 
distressing weight, and a dragging on the abdominal muscles, to- 
gether with pain and tenderness, may all supervene. Some of the 
symptoms which characterize the first stage, and disappear in the 
second, often recur in the third. Pressure on the bladder may cause 
frequent urination, and the bowels may become obstinately consti- 
pated. Paroxysms of. pain in the limbs and abdomen may be very 
severe, caused by obstructed circulation. From the same cause ef- 
fusion of fluid into the abdominal cavity and oedema of the legs may 
occur. 

The patient becomes emaciated, weak, and sometimes hectic, but 
not, as a rule, cachectic in the benign forms of ovarian tumors. 

Physical Signs. — The physical examination of ovarian tumors 
is made by the means generally employed, and fnlly described in 
the flrst chapter of this work. They are inspection, vaginal touch, 
palpation, percussion, auscultation, measurement, exploration by as- 
piration, microscopical and chemical examination of fluid obtained by 
aspiration, and, finally, laparotomy. The evidence obtained by phys- 
ical exploration difi:ers in each stage of the growth of ovarian tumors. 
In the first stage, the bimanual examination of the pelvic contents 
is all that is necessary, this giving all the information which can be 



CYSTIC TUMORS OF THE OVARIES. 491 

obtained, except in obscure cases, where aspiration may be advisable. 
Sometimes it may be necessary to pass the sound into the uterus to 
confirm or correct the impressions obtained by the touch. Occa- 
sionally, also, when the parts are tender and resisting, it is necessary 
to give an anaesthetic in order to make a satisfactory examination. 
The method of searching for small ovarian cysts in the pelvis is the 
same as that recommended in prolapsus of the ovary, and described 
in a previous chapter. Where the tumor has attained any consider- 
able size, the bimanual touch gives the most satisfactory evidence. 
The tumor, caught between the fingers of the two hands, can be 
outlined, and its consistence ascertained with a tolerable degree of 
accuracy. 

In the early stage the cyst is usually found on one side of the 
pelvis, or else in the sac of Douglas, exactly behind the uterus, or 
a little inclined to one side. It is usually soft and slightly yielding 
to the touch, sometimes globular and smooth of surface, or else 
globular in the main, with some irregular projections. These irregu- 
larities are due to the presence of small cysts and the portions of the 
ovary that remain normal. 

The physical signs obtained by this examination determine the 
fact that there is a neoplasm, and that it is possibly cystic ; but there 
is no direct, positive evidence regarding the structure of the tumor, 
nor that it is ovarian. In other words, the physical signs are not 
diagnostic — i. e., direct and positive. It is necessary, on this account, 
to employ the method of diagnosis by exclusion. 

Differential Diagnosis in the First Stage. — There are many 
affections which may present symptoms and signs remotely resem- 
bling cystic tumors of the ovary. Those which most nearly approach 
them in character are, dilatation of the Fallopian tube from hydro- 
salpinx or pyosalpinx, parovarian cysts when small, extra-uterine 
pregnancy, pregnancy in a bicornute uterus, subperitoneal fibroids 
of the uterus, fibroid tumor of the ovary, and tumors of the second 
class, which include the cystic and solid malignant growths, and in 
a less degree pelvic hematocele, pelvic peritonitis, and cellulitis. 

Fecal accumulations in the upper part of the rectum, and back- 
ward dislocations of the uterus, have also been mentioned as simulat- 
ing ovarian tumors, but these can be so easily differentiated that 
they need only to be named. Dilatation of the Fallopian tube may 
be distinguished from a cystic ovary by its oblong shape, and some- 
times, when the tube is low down in the sac of Douglas, the normal 
ovary can be felt above the tube by the bimanual touch. In case 
the dilatation of the tube is due to pyosalpinx, the history will tell 



492 DISEASES OF WOMEN. 

of a previous inflammation, and tlie constitutional symptoms are usu- 
ally more marked. Should it be necessary to make an immediate 
diagnosis, the tumor may be aspirated, and the characteristic epithe- 
lium of the tube, if found by the microscope, will decide the question. 
It is safer and surer to wait and watch the progress of the case. In 
time the ovarian tumors will grow and rise ont of the pelvis, while 
in case of a dilated tube there will not be any great increase in size, 
but there will be more local and constitutional disturbance. This 
difference in the progress of the two affections is the most reliable 
means of differentiation. Parovarian cysts can not be distinguished 
from ovarian when they are small, unless the ovary can be separated 
from the cyst, and ascertained to be normal. Fortunately, it is not 
of great importance to distinguish the one form of cyst from the 
other in the first stage of their growth. Extra-uterine pregnancy 
presents physical signs which can not always be distinguished from 
those of ovarian tumors, and in both there is a gradual increase in 
size, so that neither the physical signs nor the progress of the case 
are reliable aids in diagnosis> The general signs and symptoms are 
usually sufficient to decide. In cases of doubt, the electrical treat- 
ment which arrests the progress of the gestation should be tried. 
Pregnancy in the uterus bicornis may be detected by finding the 
other horn of the uterus, and perhaps the ovaries may be found nor- 
mal. These conditions are rare, and will not frequently come up as 
questions of diagnosis in ovarian affections. 

Small, subperitoneal fibroids of the uterus differ from ovarian 
cysts in being firm to the touch, and generally accompanied with 
enlargement of the uterus and menorrhagia. They are, when small, 
usually united closely to the uterus. An ovarian cyst is likely to 
be mistaken for a fibroid of the uterus when it is very tense and 
adherent to the uterus by inflammatory adhesions. Here, again, 
time will determine, because the ovarian will grow faster than the 
uterine tumor, and will show its characteristics more clearly the 
larger it grows. A fibroid tumor of the ovary can not be distin- 
guished from a tense ovarian cyst or a fibro-cyst of the ovary in all 
cases by physical signs, but the history will help materially in mak- 
ing a diagnosis, and, when the fibroid becomes large enough to rise 
out of the pelvis, its solid character will be easily made out. 

Neither can a fibro-cyst of the ovary be distinguished from a 
multiple cystic tumor in which the cyst-walls are very thick. But 
the diagnosis of the exact composition of such tumors is not of any 
practical importance in relation to treatment. 

Prom what has been said it will be seen that the question to be 



CYSTIC TUMORS OF THE OVARIES. 493 

decided is, Whether the tumor found in the pelvis is ovarian or not ; 
and, when that is settled, the next question v^hich arises is, What is 
the nature of the tumor ? If it can be determined that the tumor 
belongs to the first class of ovarian neoplasms, that v^^ill suffice for 
such cases. It is otherwise in tumors of the second class, because 
in malignant affections it is important to make a diagnosis early. If 
the tumor is of the first class, no harm can come from waiting, while, 
if it is of the second, surgical interference maj be necessary while 
the tumor is yet small. The physical signs of malignant ovarian 
tumors will be spoken of in another chapter, but I may briefly state 
here that the density and irregularity of outline, so commonly found 
in malignant disease elsewhere, are wanting in the cystic tumors of 
the ovary. The constitutional disturbances are usually developed 
early in malignant diseases, while it is otherwise in the benign 
forms. 

Pelvic hematocele, pelvic peritonitis and cellulitis may, after the 
acute stage of these affections has subsided, present certain physical 
signs, which may lead one to suspect an ovarian cystic tumor. But 
the history of such affections wiU put the diagnostician on his guard, 
so that time may be given to see whether the tumor which has been 
discovered grows, as it will do if it is a cystic ovary, except in rare 
cases of an ovarian cyst arrested in its growth by inflammation or 
other causes. 

Differential Diagnosis in the Second and Third Stages. — By 
the time that such a tumor has escaped from the pelvic to the abdom- 
inal cavity, and attracts attention by its presence there, it will have 
attained a size equal to that of the gravid uterus at the fifth month 
of gestation. In patients of spare habit it might be noticed sooner, 
but quite as often it escapes notice until a much later period. The 
physical signs which are of most value to the diagnostician in the 
second stage are enlargement of the abdomen, especially of the lower 
portion ; some irregularity in the form of the abdomen, one side 
being larger than the other, and the lower being larger proportion- 
ately than the upper ; the tumor is well defined and movable in the 
cavity of the abdomen, most freely from side to side. It is elastic 
and fluctuating, the fluctuation extending through the whole tumor 
if a mono-cyst, while, if a multiple cystic tumor, the fluctuation may 
be limited to sections of the tumor. The tumor does not change its 
form to any extent when the position of the patient is changed, 
neither does the form of the abdomen change. It is attached to the 
pelvic organs, and if drawn upward will drag the broad ligament 
with it. The gross and microscopic appearances and chemical com- 



494 DISEASES OF WOMEN. 

position of the fluid, obtained by aspiration are also to be regarded. 
The contents of the cyst are characteristic, to some extent, of the 
affection, as is also the appearance of the cyst as seen after opening 
the abdomen. The physical signs are very few, and none of them 
alone is diagnostic. In fact, each of them may be found in other 
conditions than cystic ovarian tumors ; hence arises the difficulty of 
making a diagnosis. The signs and the means of detecting them 
may now be discussed. 

By inspection the increased size of the abdomen is detected. In 
the second stage this is most marked at the lower portion. The 
increase in size may be uniform, the two sides being alike, or one 
side may be larger than the other, and in some cases there is an 
irregularity of outline of the tumor, which gives a nodular appear- 
ance upon inspection, and which is also apparent to the touch. A 
tumor, large enough to be noticeable in the abdomen, is usually in 
the center, and, when it is eccentric, it is because of adhesions, as a 
rule. 

The irregular outline or nodular appearance is indicative of a 
multiple or multilocular tumor. By palpation the tumor can usually 
be distinctly outlined. This is always the case, unless the tumor is 
very flaccid, and there is much fat in the abdominal walls, or the 
bowels are distended, but it is rare that these two conditions are 
found together. By grasping the tumor in both hands, it can be 
moved from side to side in the abdominal cavity. It can be felt 
sliding about under the abdominal walls. When there are extensive 
adhesions, this valuable sign, mobility, is wanting. By inspection 
the mobility may be detected by causing the patient to take deep 
inspirations and expirations, which will cause the tnmor to move up 
and down beneath the abdominal walls. This movement will be 
absent if there are adhesions. 

The vaginal touch may detect a portion of the tumor in the pel- 
vis, or may show that the round globular mass rests on the pelvic 
brim. The uterus can be made out, in a large number of cases, as 
normal, and not directly connected with the tumor, although it may 
be displaced. Beyond this, the touch per vaginam only gives valua- 
ble negative evidence. Palpation also shows that the tumor is clearly 
outlined and easily distinguished from the neighboring organs in 
some cases. When the cyst is tense, the tumor can be easily out- 
lined, but when flaccid, as often occurs, it is not by any means easy 
to map out its boundaries. 

Percussion assists in outlining the tumor when it is not clearly 
defined to the touch. The flatness on percussion over the tumor 



CYSTIC TUMORS OF THE OVARIES. 



495 



contrasted with the tympanitic resonance of the intestines, will indi- 
cate its size and position. 

The consistence can be determined by palpation, whether solid 
and very hard, solid and soft, or fluid and fluctuating. Fluctuation, 
as a sign of encysted fluid, may be obtained in several ways. If the 
tumor is a monocyst and is large enough to touch the walls of the 
abdomen on both sides, diametrical fluctuation can be obtained by 
placing the Angers upon one side, and percussing diametrically op- 
posite. The fluctuating wave will be easily found if the contents 
of the cyst are markedly fluid. If the tumor is divided into several 
sacs, fluctuation can only be obtained by palpating sections of it. 
Resting the fingers of one hand at one point on the abdomen, and 
percussing at another point a little distance from that at which the 
fingers rest, a surface wave will be produced. In case the fluid is 
semi-solid, and does not give the clear wave on percussion, fluctua- 
tion may be produced by placing the fingers of both hands upon the 
tumor some distance apart ; then, by making pressure with the fin- 





FiGS. 196, 197. — Area of dullness in ovarian tumor and in ascites (Barnes). 

gers of one hand, the contents of the cyst will be pressed under the 
fingers of the other. This is fluctuation by displacement, not by the 
wave produced by pressure. 

The fact that fluctuation is limited and does not extend through- 
out the whole abdominal cavity is most valuable evidence that the 
fluid is encysted. Further evidence of this is also obtained by an- 
other sign, that is, the tumor does not change its form when the 
position of the patient is changed. By turning the patient first on 



496 DISEASES OF WOMEN. 

one side and then on tlie other, it will be observed that while the 
tumor may gravitate to the lower side it does not change its form. 

In the second stage it can be ascertained that the tumor is at- 
tached to the broad ligament. This sign is obtained by passing the 
finger of one hand into the vagina and then pushing up the tumor 
with the other. By this means the tumor will be observed to drag 
upon the broad ligament. 

In regard to the signs obtained by an examination of the con- 
tents of the cyst, it may be said, that it is not often that this need 
be resorted to in the second stage, but when it is, the reader should 
turn to the description of the contents of ovarian cysts for all de- 
sired information on this point. 

The physical signs of ovarian and other abdominal tumors 
obtained by laparotomy are, of course, pecuhar to each. The de- 
scriptions of these appearances may help one to recognize such 
tumors when seen and felt, but much experience in observation is 
necessary to tell what a tumor is when one sees it in the abdominal 
cavity. The ambitious and rash may open the abdomen to make a 
diagnosis, and be unable to recognize that which they find. While 
I cleariy appreciate the value of laparotomy as a means of diagnosis 
in obscure cases, I am as fully aware that it should only be under- 
taken by one possessing comprehensive knowledge gained by exten- 
sive experience. 

There are certain other affections and conditions which resemble 
to some extent ovarian tumors in the second stage. The chief of 
these are pregnancy, normal and pathological, neoplasms of the 
uterus, such as fibroids and fibro-cysts; distended bladder; fecal 
impaction ; encysted fluid in the peritoneal cavity, e. g., in tubercu- 
lar peritonitis ; cysts of the kidney, liver, or spleen ; enlargement 
and displacement of the spleen, kidney, or liver; cancerous disease 
of any of the abdominal organs, omentum or abdominal glands ; and 
parovarian cysts. 

Pregnancy, in its normal state, differs greatly from ovarian tu- 
mors in all respects but the fact that both gravid uterus and the 
tumor occupy the abdominal cavity, still a number of cases have 
been reported in which an error in diagnosis was made, and ovari- 
otomy undertaken when the case was one of pregnancy. In sev- 
eral of these cases the trocar has been thrust into the uterus, the 
operator believing that he was tapping an ovarian cyst. At the 
present time such a mistake can only be made through want of 
knowledge or want of attention. One might, in trying to make a 
diagnosis, mistake the pregnant uterus for an ovarian cyst, but upon 



CYSTIC TUMORS OF THE OVARIES. 497 

opening the abdomen one having knowledge enough to warrant 
him in undertaking ovariotomy ought to be able to tell the one from 
the other by sight. 

"When there is any doubt, it is far better to wait uDtil the end 
of the time of gestation. This can always be done. There is no 
good reason for removing an ovarian cyst until it is as large or 
larger than the uterus at full term of gestation in doubtful cases. 
While I believe in removing ovarian tumors in the second stage 
of their development when the diagnosis is clear, in case there is 
room for doubt, whether the case is one of ovarian cyst or of preg- 
nancy, time will decide, and there is no valid argument against wait- 
ing. 

The fact is that those who are the least capable of making a 
diagnosis are the most inclined to operate early, and this I presume 
accounts for the mistakes recorded. 

I need not give the differential diagnosis between ovarian tumors 
and normal pregnancy ; the symptoms and signs of the former have 
been given, and those of the latter can be found in any text-book on 
obstetrics, if not already familiar to the reader, and they are so very 
different that by contrast the diagnosis can be made. 

Extra-Uterine Pregnancy. — This usually comes up for diagnosis 
in connection w4th the first stage in the growth of ovarian tumors, 
as has already been stated. It is only the abdominal variety which 
in any way resembles ovarian tumors in the second stage. The 
signs of a living child in the abdomen are so perfectly diagnostic 
that they can hardly be mistaken. In case the child is dead, more 
difficulty might be experienced in making a diagnosis. The history 
of the case and hallottement^ or the ability to move the dead child in 
the sac, will usually suffice to settle the question. 

Rupture of an Ovarian Cyst. — This, and the extensive adhesions 
which follow, most closely resemble ventral pregnancy after the 
death of the child, both in history and in physical signs, and I can 
understand that it might be impossible to discover the exact nature 
of the trouble w^ithout the aid of laparotomy. Fortunately, under 
these circumstances it would be perfectly right to employ this 
method of making the diagnosis, because it is part of the appro- 
priate treatment in either case. 

In the cases of abdominal pregnancy that I have seen the diag- 
nosis was very easy ; so much so that no one with any experience 
could have made the mistake of suspecting ovarian tumor. 

Uterine Fibroids and Fibro-Cysts, when large, present some of 
the evidences of ovarian tumors. The position of the tumor in the 



498 DISEASES OF WOMEN. 

abdomen, and its shape and mobility, are the same as those of some 
ovarian tumors, and these are the only resemblances. 

In fibroids, the uterus is enlarged as shown by the tonch and 
sound. The tumor is solid and is intimately connected with the 
uterus, in fact forms a part of it. In the majority of cases the cav- 
ity of the uterus can be probed, and will be found enlarged in case 
the tumor is uterine, while it will not be if the tumor is ovarian. 

Distended Bladder has been mistaken for a cyst of the ovary, 
but only at a first examination or by one not used to such cases. 
When the bladder is overdistended there is incontinence, usually 
the urine coming away constantly, or in spurts when the patient 
moves. This leads the medical attendant to suppose that the blad- 
der must be empty and that the tumor is an ovarian cyst, but the 
catheter readily settles the question, and it should always be used in 
cases with such histories. 

Fecal Impaction has always been mentioned as one of the condi- 
tions which might be mistaken for an ovarian tumor, but I have not 
considered such a thing possible. The irregular form and solid 
character of the fecal mass differs in every respect from ovarian 
tumors of all the benign variety. 

Encysted Dropsy of the Peritonaeum. — This is an extremely rare 
affection and occurs in the progress of tubercular disease as a rule, 
and follows an attack of peritonitis. The physical signs differ, in 
that the fluctuation is not so general as in ovarian cyst, and the fixa- 
tion is complete. The surface of the abdomen is not so prominent 
as in case of a cyst, but often has irregular depressions, as well as 
elevations, and the veins are not prominent. 

The general health is greatly reduced early in the progress of 
the disease ; nutrition is markedly impaired, and there is often sep- 
ticaemia in case that there is pus encysted. 

The vaginal examination is often quite sufficient to settle the 
diagnosis, by showing that the pelvic organs are normal and can be 
outlined and separated from the mass in the abdomen. When this 
can be accomplished, ovarian disease is at once excluded. 

Enlargement and Cysts of the Liver, Spleen, and Kidneys. — In all 
of these the diagnosis, so far as the exclusion of ovarian disease, can 
be easily made if the cases are seen early, or a correct history can be 
obtained. It is found that in them all the enlargeujent begins 
above and on one side, and, as a rule, is fixed there from the begin- 
ning, and the pelvic organs can be separated from the tumor above, 
and proved to have no connection with the morbid growth, and to 
be normal. These two diagnostic facts will suffice in most cases to 



CYSTIC TUMORS OF THE OVARIES. 499 

settle tlie question, but additional evidence can be obtained from the 
general history of the growth and its effects upon the general 
health, also the composition of the fluid in cjsts, which should be 
obtained by aspiration in doubtful cases. 

In regard to the differential diagnosis in cancer of the pelvic and 
abdominal organs, this will be discussed in connection with these 
affections, and hence is omitted here. 

Parovarian Cysts, or serous cysts of the broad ligament, as they are 
called, are not very easily recognized at all times. Fortunately it 
would be no very great mistake to remove one of these cysts suppos- 
ing that it was an ovarian cyst. They are very rare as compared 
with ovarian cysts, they grow slowly, and occur mostly in young per- 
sons. The general health does not suffer, as a rule. The physical signs 
differ in no way from those of the ovarian monocyst, except that 
the fluctuation is more distinct and the fluid differs, being clear like 
water and without albumen. Tapping, or rather exploratory aspira- 
tion, is the means to be employed to settle the diagnosis, and should 
be practiced when there is a doubt. 

Affectons which resemble Ovarian Neoplasms in the Third Stage. 
— There are only a few affections which resemble ovarian cysts in 
the third stage. These are ascites, uterine flbro-cysts, and very large 
uterine fibromata. 

The first mentioned, ascites, is the most likely to be mistaken for 
ovarian cyst. The chief points of difference in history are, that as- 
cites is, as a rule, preceded by some acute disease or general ill- 
health, suggestive of some chronic disease of the liver, heart, or kid- 
neys. There is anasarca also in most cases of ascites, and the pa- 
tient is generally anaemic early in the progress of the disease. The 
enlargement of the abdomen comes on rather suddenly, and is not 
confined to its lower part ; that is, it is not circumscribed. The ex- 
pression of the face, while showing ansemia in ascites, is not anxious, 
as it usually is in ovarian cyst. The history of ovarian cyst in 
growth and general constitutional symptoms is almost the reverse of 
ascites. 

The physical signs of ascites diflPer from ovarian cyst, chiefly in 
that the fluid in ascites changes its position with every change in the 
position of the patient. When the patient is placed upon the back, 
the abdomen is symmetrical and flat ; in the erect position, the lower 
portion bulges from the gravitation of the fluid, and the same 
change in the position of the fluid occurs wdien the patient is turned 
toward either side. With these changes in the position of the fluid, 
there is a change in the resonance on percussion The flatness is 



500 DISEASES OF WOMEN. 

found at the most dependent part, while the resonance is found at 
the upper. 

In large cjsts there is dullness or flatness on percussion at all 
points except the flanks, where there is alwaj^s resonance, except 
when the colon is distended with gas and fixed deep in the side, so 
that the fluid of ascites can not gravitate below it ; and in ovarian 
cjst there may be dullness on percussion in the side due to fecal im- 
paction of the colon. 

There is another exception to the rule that in ascites there is 
always resonance at the highest point of the abdomen whatever the 
position of the patient may be, and that is when the disturbance 
of the abdomen is extreme, and the mesentery is not long enough 
to permit the intestines to rise to the toj) of the fluid while the pa- 
tient is upon the back. There is also a difference in the fluids, which 
gives some help in the diagnosis in case aspiration is practicable, as 
it may be in doubtful cases. 

Uterine Fibro -Cysts or Fibromata seldom attain sufficient size to 
resemble ovarian cysts, but occasionally they do so. The fibro-cysts 
of the uterus more closely simulate the ovarian cystic tumors than 
the fibromata. The difference in the history and the fact that the 
uterus is involved in the tumor in fibro-cyst and free in the other 
form, are the chief points of difference. This subject was discussed 
in treating of the diagnosis in the second stage of ovarian tumors, 
and need not be repeated in full in this connection. 

Intraligamentous Ovarian Cystomata. — 1 deem this variety of 
ovarian tumor of sufficient importance to merit a separate consid- 
eration. 

The difference between intraligamentous and the ordinary forms 
of ovarian cystomata is simply in the position they occupy in rela- 
tion to the ligaments. The location may be called an unnatural one, 
because it differs from that which ovarian cystomata usually occupy. 

The intraligamentous ovarian cystomata are comparatively quite 
rare. This suggests that the causes operative in determining their 
location are exceptional. Two theories have been advanced to ex- 
plain the topographical anatomy of intraligamentous cystomata. The 
one assumes that, owing to some error of development, the ovary, 
during embryonic life, finds its way into the folds of the broad 
ligament and there remains. In that case, if a cystoma of the abnor- 
mally located ovary occurs it is certain to split up the ligament and 
convert it into a capsule for itself. 

The second theory is, that during the growth of the cystoma it 
burrows, so to speak, into the folds of the ligament, and once having 



CYSTIC TUMOES OF THE OVARIES. 501 

insinuated itself there pushes the folds apart, and these folds grow 
with the cystoma and form a ligamentous capsule for it. In order 
that this may come about, the ovary must be closely attached to the 
ligament, in place of being held by a special fold of peritonaeum, 
which leaves it to some extent free from the ligament j^roper. Or 
the ovary may be bound down to the ligament by an inflammatory 
adhesion. Where a cyst develops deep in the ovary and meets re- 
sistance on the free peritoneal surface, it pushes its way in between 
the folds of the ligament. There is good evidence in favor of this 
theory in the fact that these cystomata come from the paroophoron, 
which is the portion of the ovary that is nearest to the uterine 
ligament. Furthermore, I have in one of my own cases found the 
ovary from which the cystomata came imbedded in the posterior 
fold of the ligament. It would be more correct, perhaps, to say that 
the ovary was stretched out upon the posterior fold of the ligament. 
It was so changed in form that I should have overlooked it had it 
not been that there were several small cysts in it surrounded by 
what appeared to be ovarian stroma. 

In another case I found, while enucleating the cyst, that it was 
very firmly adherent at a point in the posterior fold of the liga- 
ment where the ovary should be found. The vessels were larger at 
that point than anywhere else, which led me to think that the ovary 
was there ; but the tissues were so changed by inflammatory products 
that I could not positively detect any ovarian tissue. This, I think, 
is sufficient to settle this point in the pathology and causation of some 
of these cystomata, and presumably the larger portion, if not all, of 
them. Still, it may be admitted that malposition of the ovary, be- 
cause of a lesion of development, may obtain in some cases. 

Pathology. — These cystomata may be single or multiple. I 
think, however, they are more often single. All of my own cases, 
eight in number, have been monocysts. Another interesting feature 
is that they are generally papillary or proliferous cysts. This, ac- 
cording to some authorities, notably Bland Sutton, of London, is due 
to the fact that they are developed from the deeper structures of the 
ovary, the paroophoron, as already noted. 

The position of these cystomata and their relations to the pelvic 
organs have a very important bearing upon the question of treat- 
ment, as will be seen farther on. 

In my own practice, I have found them occupying widely difl'er- 
ing positions in relation to the ligaments and pelvic organs. In 
some, the tumor was situated in one ligament, displacing the uterus 
to the opposite side of the pelvis, and, in a lessoi- degree, the bladder 



502 DISEASES OF WOMEN". 

also. In others, the tumor occupied a position in both ligaments and 
between the uterus and bladder. When thus located the tumor, 
uterus, bladder, and ligaments have been found high up out of the 
pelvis, so that the most dependent portion of the tumor could not 
be easily reached through the vagina. Again, I have found the 
tumor behind both the uterus and bladder, and yet between the 
folds of both ligaments. In all these the pelvic organs were 
carried up into the abdominal cavity, while the tumor descended 
deeply into the pelvis. It appears that there is a rule which deter- 
mines the location of those tumors which occupy both ligaments, in 
regard to their relations to the pelvic and abdominal cavities. This 
rule may be formulated as follows : When the tumor is between the 
uterus and bladder, all three structures rise up into the abdomen; 
whereas, if both of these organs are in front of the tumor, it dips 
well down into the pelvis. The reason is, that in the one case the 
vagina arrests the process of burrow^ing downward, while in the 
other there is no resistance to the descent of the cystoma. 

In all cases the broad ligaments become greatly enlarged and 
thickened, usually covering the whole cyst, although they are thinned 
out at the upper portion. When the cyst does not descend into the 
pelvis and has attained considerable size, the upper portion of the 
cyst may present a wall of medium thickness ; in fact, the liga- 
ments diminish in thickness and vascularity until there is little left 
but the peritonaeum ; and the upper part of the cyst then appears 
more like an ordinary intraperitoneal ovarian cystoma. 

These facts are of the utmost importance in regard to treatment, 
and hence the reason for this brief account of the various positions 
in which these intraligamentous cystomata may occur. 

Symptomatology. — These tumors cause more pain and functional 
derangement of the pelvic organs than the ordinary ovarian cysto- 
mata, but in other respects the history is the same. 

Physical Signs. — The diagnosis of such cases is of interest chiefly 
because of the difficulties encountered in operating and the urgent 
necessity of clearly comprehending the exact conditions present, in 
order to manage them to the best advantage. I have found it im- 
possible to make a complete and comprehensive diagnosis in all 
cases. It is generally possible to make out that there was a cystoma 
in the broad ligament, but with no definite certainty as to its posi- 
tion and topographical anatomy. Judging from the literature of 
the subject, it appears that others have suffered from a like uncer- 
tainty in some cases. When a cystic tumor exists in the abdomen 
and is firmly fixed below, with no history of inflammation during the 



CYSTIC TUMORS OF THE OVARIES. 503 

earlier stages of the growth of the tumor, and the uterus is drawn 
up out of the pelvis and lies behind or in front of the cystoma, I 
suspect that it is intraligamentous. If the uterus is displaced later- 
ally in a marked degree by the cystoma that is present, or if tlie 
cyst descends deep down into the pelvis while the uterus is high up 
and in front of the cyst, the facts point to the same conclusion. 
When a portion of the tumor found in the pelvis is cystic, this is a 
great aid ; but, as a rule, these tumors, as already stated, are prolifer- 
ous, and there is so much solid material in the most dependent part 
that fluctuation is not found, and the tumor appears to be solid to the 
touch and may be mistaken for a fibroma or fibrocyst of the uterus. 
One case was seen by two well-known ovariotomists, and both sus- 
pected fibroma of the uterus as well as ovarian cystoma. My first 
impressions w^ere the same, but upon opening the abdomen I found 
the uterus normal, but displaced upward by an intraligamentous 
ovarian cystoma. 

Cases may be divided into two classes — those in which a com- 
plete diagnosis can be made, and those in which the diagnosis is 
incomplete. In the one, the nature and composition of the tumor, 
its relations to the abdominal and pelvic organs, and the extent and 
location of its attachments, can be clearly determined ; in the other, 
w^hich is incomplete, there may be sufiicient evidence to warrant 
either operative treatment or a full assurance that the case is not 
amenable to surgical treatment. The first or complete diagnosis can 
be made from the usual physical signs and the history. The incom- 
plete diagnosis may be made complete by surgical means, such as 
aspirating or by laparatomy. It is of the utmost importance to dif- 
ferentiate between these two classes of cases. When only a partial 
diagnosis can be made, leaving doubts as to a possible malignant ele- 
ment existing in the case, the question of the propriety of ovariotomy 
may be determined by an examination of the intraperitoneal fluid, 
which is often present. If this proves negative, the operation is 
advisable ; while, if the cells characteristic of malignant disease are 
found, the case should be left alone. Keeping still to the question 
of diagnosis, I may say that in cases of intraligamentous cystomata 
one can usually make sure that an operation is called for and is jus- 
tifiable, but the diagnosis must often remain incomplete until the 
abdomen is opened. At the same time it is not an easy task to com- 
plete the diagnosis after laparotomy. A few words on this subject 
may be admissible, in view of the importance of the matter. We 
hear much of making an exploratory operation for diagnostic pur- 
poses, but I am satisfied that skill and experience ai*e very necessary 



504 DISEASES OF WOMEN. 

to do this. To recognize just what is present, and to determine what 
to do in these cases when the tumor is exposed, is no easy task ; and 
still, upon a rapid inspection and palpation, and prompt decision 
regarding the exact conditions and how to manage them, depends 
the success of the surgeon in complicated cases. I may not liave 
seen or carefully thought of all the conditions which simulate, and 
hence may be mistaken for, intraligamentous cystomata, but such 
observations as I have made cover the most important part of the 
ground. 

When the tumor is exposed by laparotomy its intraligamentous 
character can he determined by incising the peritonseum, which wdll 
retract and expose the cyst-wall. In all other tumors the perito- 
naeum is so closely adherent that no retraction occurs. The appear- 
ance resembles most closely a uterine fibroma, and owing to the 
thickness of its walls it feels to the touch like a fibroma, especially 
if the cyst has very tense walls, as usually is the case ; but by rest- 
ing one finger on the tumor and percussing the abdominal wall 
at a distant point, fluctuation can be unmistakably made out. This 
excludes fibroma at once, but still leaves the possibility of the tumor 
being a uterine fibrocyst, and, although this is not important as bear- 
ing upon the main question of removal of the tumor, it affects th6 
method of procedure and should be correctly decided at once. This 
can be done by tapping, which shows the character of the fluid, 
which is all-sufiicient, with few exceptions. If pus is found, it may 
be impossible to say whether the cyst is uterine or ovarian. The 
tapping, however, gives more room for the introduction of the hand, 
which enables the operator to make out the attachments and the 
relation of the tumor to the pelvic organs, and thereby complete the 
differentiation. 

The pregnant uterus also looks, in color and vascularity, like this 
form of tumor, and may lead to doubt. At least I think that when 
this mistake has been made, an intraligamentous tumor must have 
been suspected, because it is the only ovarian cystoma that appears 
at all like the uterus. This can be made clear by observing con- 
tractions of the uterus, which can be easily excited, and by passing 
the hand into the abdomen the ovaries can be found, and the condi- 
tion of the cervix uteri and normal ligaments will show that there 
is pregnancy. 

Treatment. — These tumors require special treatment, owing to 
the fact that they are not pedunculated like the ordinary cystomata, 
but are encapsulated, and differ in their relations to the pelvic 
organs. 



CYSTIC TUMORS OF THE OVARIES. 505 

The several methods adopted in operating are as follows : Enu- 
cleation ranks first, because it is adapted to more cases, perhaps, than 
any other. This well-known method, devised and introduced by 
Dr. Miner, of Buffalo, has been practiced by many ovariotomists. 
It was employed in the treatment of ordinary pedunculated cystoma 
when first brought out, and is now seldom practiced except in par- 
ovarian cysts. In fact, I do not think that Dr. Miner ever employed 
his method in the treatment of the class of cases now under con- 
sideration ; but if he did, he omitted a description of some of the 
details which are necessary. Enucleation is adapted to all cases in 
which the cystoma descends into the pelvis, completely separating 
one or both ligaments. In all such cases it should be tried, and it 
will succeed well unless there has been inflammatory action which 
has firmly united the cyst-wall and folds of the ligaments, or the 
cyst-wall is thin and friable. 

In such conditions the enucleation may prove to be impossible, 
and other means of treatment, to be hereafter noted, must be adopt- 
ed. In the first place, it is important to tap the cyst high up, in 
order to avoid wounding the thickest portion of the broad ligament. 
To do this it is sometimes necessary to extend the incision in the 
wall of the abdomen higher than usual. The cyst being emptied 
and drawn well out of the wound, the separation of the ligament 
and cyst-wall should be begun at that point high up where the liga- 
ment is so thinned out as to be hardly noticeable. "When the dis- 
section is begun all around, the capsule can be lifted up and the 
dissection continued with the knife-handle, and finally the deeper 
portions can be separated with the finger. The traction should be 
made upon the cyst-wall, as the capsule or ligaments is easily lacer- 
ated. During enucleation, if any large vessel, artery, or vein is in- 
jured, it should be ligated or controlled with forceps at once. The 
management of the ligaments, after the cystoma is removed, is first 
directed to the control of haemorrhage. In some cases a general 
oozing is all that there is. Occasionally a wounded vessel here and 
there needs ligating. When the cyst extends deep down into the 
pelvis, there is often very troublesome bleeding from veins. These 
should be ligated, if possible ; but if that can not be done, pressure 
with a hot sponge should be tried, and, if that fail, styptics may be 
used. The ligamentous capsule now presents a pouch, the inner 
surface of which is raw, and from which there will be some bleed- 
ino^ and much serous oozing. This should be treated as follows : 
The upper portion of the opposing sides should be folded in so as 
to bring the peritoneal surfaces together, and these should be fixed 



506 DISEASES OF WOMEN. 

by a continuous catgut suture. The suturing should begin on 
both sides, and be from the sides toward the center, and close the 
parts, except at a point beneath the abdominal wound, where an 
open space should be left for the drainage-tube. If the ligaments 
thus approximated by sutures can be brought up to the lower 
angle of the abdominal wound, they should be fixed to the abdomi- 
nal wall by silk sutures passed through the ligaments on each side 
of the opening for the drainage-tube, and then through the wall of 
the abdomen. When the ligaments can not be brought up to the 
wall of the abdomen, a drainage-tube without side-openings, should 
be carried down to the bottom of the cavity. 

While this mode of treatment is perfectly satisfactory in suitable 
cases, there are difficulties attending the operation in exceptional 
cases, and hence certain dangers The cyst- wall may be easily torn, 
and there is liability of leaving portions of it. When this happens, 
it is necessary to destroy the secreting surface. This may possibly 
be done by a^^plying pure carbolic acid. The most difficult part of 
the operation is, in some cases, to stop the bleeding. This has been 
referred to ; but I may say further, that the oozing at the time of 
operating, and the liability to suppuration which may occur after- 
ward, render the convalescence rather tedious in many cases. 

The next procedure is to remove the cystoma, and its capsule 
also, by ligating the ligament below the tumor. This method is 
adapted to those cases in which the cyst is situated in one broad liga- 
ment and does not dip down very far into the pelvis. Such cases 
are described in books as having a very broad pedicle, but the most 
that can be correctly said of them is that they are partially pedun- 
culated. In this condition the ligament can be ligated with the 
repeated continuous ligature. This is applied in the following man- 
ner : One end of the ligature is passed through the ligament and a 
portion of it tied, then the other end of it is passed through the 
portion which is already ligated, carried forward, and brought back 
through the ligament in such a way as to secure another portion, 
and the two ends again tied, and so on until the whole is secured. 
The cyst and its capsule are then cut oif. This leaves no cavity, 
arrests all possible haemorrhage, and in this respect is all that can be 
desired. But there are difficulties and dangers that may arise, even 
in cases where the method is applicable. There is danger of wounding 
the ureter or including it in the ligature. A knowledge of the loca- 
tion of the ureter and its anatomical relations is not always sufficient 
to guard against this accident, because the ureter may be displaced. 
By drawing the cyst and ligament out of the abdominal wound, it 



CYSTIC TUMORS OF THE OVARIES. 507 

may be possible to see that the ureter is not in the way ; but this 
can not always be done, and then one has to depend upon the touch 
to localize the ureter and avoid it. This is possible, owing to the 
fact that the ureter feels like a cord crossing the ligament ; but in 
case the tissues are thickened by inflammatory products it is difficult 
indeed to find the ureter. 

There is still another way of managing these cases, and that is 
by a combination of the two methods already described. It is well 
adapted to cases that can be enucleated easily, and has the advantage 
of surely avoiding the ureter. The cyst is first enucleated, and the 
capsule, or so-called pedicle, is tied and cut off. The advantages 
are, that it is easier to handle the capsule after the cyst is removed, 
and there is no danger of including any portion of the cyst in the 
ligature — an accident that may occur in operating by the second 
method alone. There is one fortunate feature in this method of 
treatment, viz., in case enucleation can not be effected, ligation alone 
can be resorted to. It is well, then, to try enucleation, even if it has 
to be abandoned. 

There still remain for consideration tumors that can not be re- 
moved by any of the methods known at the present time, and there 
are such. A cystoma that descends into the pelvis and has become 
firmly adherent to the ligaments by inflammatory products, can not 
be enucleated, neither can the capsule be ligated. At least enucle- 
ation can not be done with any degree of safety. That complete 
removal of such tumors has been tried, is no doubt true, but the 
result has been to open into the rectum, and cause uncontrollable 
bleeding or peritonitis, either of which must prove fatal. These 
complications are always present in suppurating intraligamentous 
cystomata, and hence when pus is found on tapping, it may be in- 
ferred that enucleation is impossible. I have found, however, that 
a non-suppurative cellulitis has so firmly united the cyst- wall to the 
ligamentous capsule that they could not be separated. The treat- 
ment of such cases is by drainage. I am well aware that the more 
skillful the operator, the more surely w^ill he overcome difiiculties, 
and the more frequently will he have complete operations ; but when 
the conditions which have been named are present, I am confident 
that it is wiser and better to empty the cystoma and unite the cyst- 
wall to the abdominal w^all, and then drain by means of the ordinary 
tube. The cyst fiuid is usually septic (this is always so in suppu- 
rating cysts), and it is very difficult indeed to save the peritonanmi 
and abdominal wounds from contamination. After emptying the 
cyst and opening it, it should be thoroughly cleaned out with sponges 



508 DISEASES OF WOMEN. 

or absorbent cotton, and papillary tissue, if present, may be scraped 
off. This should be done with the cyst drawn well out of the wound. 
If the cystoma is large, an effort should be made to separate the cyst- 
wall from the capsule as far down as possible. If that can be done, 
the detached portion of the sac is then cut off, leaving it of suffi- 
cient length so that the central portion will come up to the abdominal 
wall without dragging. Bleeding vessels in the cyst-wall are ligated 
or twisted. The detached portions of the capsule are folded into 
the cyst and united with a continuous suture, beginning on each side 
and continuing toward the center, but leaving space enough between 
their meeting to admit the drainage-tube. In this, great care has to 
be taken to keep the hands and instruments, which have touched 
the inside of the cyst, from coming in contact with the peritonaeum 
or abdominal wound. Again, in fastening the partially closed cyst 
to the abdominal wall, it is necessary to pass the needle from the 
abdominal wall into the cyst, and not use that needle again unless it 
is thoroughly cleansed. If, on the contrary, the sutures are passed 
from the inside of the cyst outward, septic material will surely be 
carried into the tissues of the abdominal wall, and trouble will fol- 
low. One suture on each side of the opening in the cyst for the 
drainage-tube will suffice to unite the wall of the cyst and the ab- 
dominal wall at these points ; and one suture above, and one below, 
carried through the sides of the abdominal wall, and into the cyst- 
wall, but not through, will complete the coaptation. If this much 
is accomplished without contaminating the normal tissues, there is 
very little danger of septic peritonitis occurring, or septic inflamma- 
tion of the abdominal walls. The drainage is so perfect that, though 
suppuration in the remaining portion of the cyst may go on, there 
is not much danger from it if it does not extend outside the sac. 
The drainage must be long continued, and the convalescence is very 
slow, comparatively. In case the secreting surface of the cyst has 
been thoroughly destroyed by suppuration, the recovery is usually 
not long delayed. Contraction and closure of the cavity come in a 
month or thereabout. If, on the other hand, the secreting surface 
is left, the discharge may go on for months ; but the patient, mean- 
time, may completely regain her health and be able to attend to her 
duties comfortably. When a small pocket and sinus remain, it 
facilitates recovery to inject iodine or carbolic acid. I may be preju- 
diced in favor of this mode of treating such cases from the fact that 
I have had two intraligamentous cystomata and four adherent ordi- 
nary ovarian cystomata which were treated by drainage, and all 
recovered. 



CHAPTER XXYIII. 

OVARIOTOMY. 

The operation of renoving ovarian tumors has been generally 
known as ovariotomy. Every one understands the meaning of the 
term, established by usage, as indicating the removal of the ovaries 
when the subjects of morbid growths. Since Dr. Battey introduced 
the procedure of removing the normal ovaries the term oophorectomy 
has been used more frequently, and there appears to be a disposition 
among some to use the term ovariotomy when speaking of the re- 
moval of ovarian tumors, and oophorectomy when referring to the 
removal of the ovaries when not enlarged. This use of two terms 
which mean exactly the same thing is confusing in any case, but 
much more so when an attempt is made to make the terms indicate 
different operations. I shall use the term ovariotomy in all cases 
when treating of the removal of the ovaries, no matter what theii' 
condition may be. 

Ovariotomy has in the past been the term used for the operation 
which includes the removal of the Fallopian tubes with the ovaries. 
In nearly all the ovarian tumors the Fallopian tube is so united to 
the neoplasm that removal of the one necessitates the removal of the 
other. 

The operation first practiced by Tait and Hegar of removing the 
tubes when diseased along with the ovaries, is now quite generally 
spoken of as removal of the uterine appendages. This is a veiy un- 
satisfactory way of expressing the fact. It is absurd to speak of the 
ovaries and tubes as appendages of the utenis. One might a? well 
speak of hysterectomy as the removal of the ovarian appendage. 
In the evolution of development the uterus is added to the ovaries 
and tubes in the higher animals, and ovaries, tubes, and uterus have 
independent structures and functions ; hence, neither one is an ap- 
pendage to the other. To designate the operation of removing the 
ovaries and Fallopian tubes, I shall use the term tubo ovariotomy. 



510 DISEASES OF WOMEN. 

GENERAL CONSIDERATIONS OF OVARIOTOMY. 

Before taking up the details of the operation, I shall call atten- 
tion to certain general facts which belong to all snrgical procedures, 
and have a special bearing on ovariotomy. While most that will be 
said pertains to the removal of ovarian tumors, it will be equally 
applicable to the removal of the small-sized diseased ovaries or nor- 
mal ovaries and tubes, the more modern operation. 

I have long entertained the opinion that ovariotomy is the most 
difficult operation in the whole field of surgery. This is, however, 
a matter of opinion, and may be an error on my part, but it is posi- 
tively certain that a thorough knowledge of surgery and all attain- 
able dexterity and skill in operating can be employed wdth advan- 
tage in removing ovarian tumors. This operation differs from all 
others that I know of, in the number and variety of complications 
which it affords. It is seldom that two cases exactly alike occur in 
the practice of any surgeon, hence it is not until a very large num- 
ber of cases have been seen that the operator is prepared to meet 
all the conditions which may come before him. To the operator of 
limited practice, the operation in this respect often presents the 
characteristics of a new investigation. To this extent, then, the 
operation is unlike anything else in surgery. Most all other 
operations are, to a great extent, definite ; the anatomy being the 
same and the modus operandi fixed according to well-defined rules. 
The surgeon has it in his power to learn such operations by practice 
upon the cadaver, until he may be almost master of his work (if he 
has in him the surgical diathesis) before touching the living subject. 
No such opportunity is offered to acquire the art of doing ovariot- 
omy. The division of the abdominal walls, the first and simplest 
step in the operation, may be studied and practiced upon the cada- 
ver, but here ends the value of dissection as a S23ecial aid to the ova- 
riotomist. 

Books and lectures, then, "are the most available sources of in- 
formation, but this reading and listening to others talking, although 
a means of acquiring a knowledge of science, is a poor way of learn- 
ing how to perform an operation. 

It is true that one may familiarize himself with all the steps of 
an operation and the complications which may be found in each case, 
and he may be able to recall them at will, and think of them clearly 
before and after an operation, but to recognize the indications and 
promptly meet them while operating, can only be learned by prac- 
tical observation. 



OVARIOTOMY. 511 

The first essential, then, is to know how to operate — a self-evident 
proposition this, which need not be made here were it not for the 
fact that many try to perform ovariotomy who are not qualified to 
do so. It is a notorious fact that this most important of operations 
has been performed by many who had no claim to being called sur- 
geons. Obstetricians who, having turned their attention to some of 
the plastic operations of gynecology and succeeded, have next taken 
to ovariotomy. A few, bolder still, have made their debut in sur- 
gery as ovariotomists, without any previous surgical experience. 
Why men should be found who will undertake this operation while 
they would shrink from iridectomy or lithotomy, is a difficult ques- 
tion to answer. Perhaps the difiiculties in the way of learning to 
do this operation may account for it. 

It is clearly evident that one should be well grounded in 
the science and art of surgery before taking up ovariotomy. The 
consummate surgeon can readily transfer his art to this department 
of abdominal surgery with far more hope of success than one who 
seeks to acquire skill by practicing ovariotomy as his maiden effort. 

The best and surest way of all to qualify for this operation is to 
secure facility in general surgery, and then to take lessons of some 
successful operator ; to witness, and if possible to assist in, a suflficient 
number of operations so as to see the different kinds of cases and the 
various complications. By such means the surgeon can secure one 
great element of success, a knowledge of manipulations. Next to 
knowing how to operate is how to obtain competent assistants. An 
operator of large experience may be able to do the operation with 
assistants who know little, if anything, of the operation, his famil- 
iarity with the work being such that he can give much of his atten- 
tion to those who are helping him, and so command success. It is 
quite different with one of more limited experience. His whole 
time and attention are taken up with that which he is doing himself, 
and if his assistants are unacquainted with their duties, they gener- 
ally hinder rather than help. It is a sad sight to see a beginner, 
with untrained assistants, trying to do ovariotomy. The ease with 
which such assistants make simple things complicated and lose time 
in hurrying is quite extraordinary. I know this from having played 
the role of operator and also assistant when I did not know either 
of the parts. 

Skill in diagnosis is a means of success of primo importance, 

and for many reasons should have been disposed of fii*st ; but I put 

the operation first in my argument simply because I believe that 

more failures come from poor operating than from en-ors in diagnosis. 

24 



512 DISEASES OF WOMEN. 

The text-books give all the rules and means of diagnosis so fully 
that no one needs more theoretical instruction — but here again much 
practice is needed. Diseases of the ovaries present such variety of 
physical signs that a very large experience is required to see all the 
different kinds of cases. Ovarian tumors differ so in their form, 
composition, and complications in the way of adhesions, that their 
real nature is difficult to make out. Again, there are many abdom- 
inal tumors and products of disease which simulate in their physical 
signs ovarian tumors so closely, that experts of long practice are at 
times unable to make a correct diagnosis. Still, great accuracy can 
be attained in diagnosis by long and careful observation. In many 
affections we can successfully adapt our treatment to the deranged 
conditions manifested, although the exact nature of the pathology 
may be unknown ; but in ovarian tumors we must have rather definite 
ideas of their character before we can begin their surgical treatment. 

Ovariotomy, as an operation, differs so much with the different 
operators, both as regards the methods of procedure and results ob- 
tained, that I propose to notice some of the conditions upon which 
the success apparently depends. 

Dexterity on the part of the operator and all available means 
which save time and secure accuracy are obvious necessities, and 
need not be urged in this connection. In an operation of such 
magnitude the question of anaesthetics requires a passing notice. 
Sulphuric ether has still the best reputation. Its administration 
should be prompt and carefully kept up. The less ether that the 
patient takes the less the danger and the better the condition of the 
patient afterward. Fifteen or twenty minutes wasted in ansesthetiz- 
ing give just so much unnecessary blood-poisoning, and this to 
some extent retards recovery. Giving nitrous-oxide gas first, and 
following it up with ether, is the most rapid way of anaesthetizing. 
I have seen this method employed by others with great satisfaction. 
I use ether altogether, and administer it with the apparatus already 
described. I believe that the great majority of ovariotomists use 
this anaesthetic, and I am perfectly satisfied with it when it is given 
in the way that I have mentioned 

There are a number of points of importance which might be 
discussed in this connection in regard to the different methods 
which surgeons employ in performing certain steps of the opera- 
tion. "When describing the operation I shall give the methods 
which in my judgment are the best, but a general discussion of 
some of these matters appears to be necessary in order to show 
reasons for my preferences. 



OVARIOTOMY. 



513 



In the management of the pedicle, for example, we find that 
even the renowned operators do not all agree. Through the influ- 
ence of the most successful of all operators, I am firmly convinced 
that the cautery gives the best results, and I am also satisfied that it is 
because the method of using it is not fully understood that it is not 
more generally employed. The object is to desiccate at least half an 
inch of the end of the stump and to avoid charring it. This can 
only be accomplished by strongly compressing the pedicle, using a 
heavy clamp, with blades half an inch thick, and then heating it 



C-.:-- 







Fig. 198. — Cautery clamp. 



with a very heavy cautery until the portion in the grasp of the in- 
strument is thoroughly desiccated. The stump thus treated looks 
like a piece of translucent horn. The divided ends of the vessels 
are completely closed, which guards against haemorrhage. I pre- 
sume that the end of the stump does not slough, but becomes 
hydrated, and finally organized. 

The advantages of the cautery may be briefly summarized as 
follows : 

It is a reliable way of controlling haemorrhage ; it leaves the stump 
in a condition requiring the least reparatory care ; and, finally, it avoids 
all sources of irritation such as that to which tlie ligature gives rise. 

I have recently employed a cauteiy clamp which, I think, has 
some merits worthy of notice. It compresses the pedicle on four 
sides. The long blades keep the tissues from spreading, while the 
short sliding blade presses the tissues against the other cross-bar. 
The advantage of this is that the pressure upon the pedicle is equal 
at all points, and it thereby gives a smaller stump. The trouble 
with the old straight clamp is, that it spreads out the pedicle too 
much, and while it firmly holds the centnil or thickest part, the 
outer edges are liable to slip out of its grasp. 



514 DISEASES OF WOMEN. 

The next, and perliaps the most important, essential of success is 
cleanliness, or, to put it technically, the antiseptic method of operat- 
ing. Surgeons were beginning to feel a certain sense of security in 
performing ovariotomy when they carried out all the details of the 
Listerian method ; but more recently they have found that carbolic 
acid in place of saving patients, sometimes sacrifices them. When 
the danger of carbolic-acid spray in ovariotomy was first announced 
many surgeons thought that Thomas Keith had given up antiseptic 
surgery ; but that great surgeon is still as earnest and enthusiastic in 
his war against dirt as he ever was. Although he has given up the 
use of the spray, because he found that the good that it did was 
counterbalanced by its injurious effects, he still retains all the other 
known elements of antiseptic surgery. These elements I under- 
stand to be, first, to keep wounds free from extrinsic germs, which 
are in themselves injurious to living tissues, or which favor morbid 
action in the tissues ; and, on the other hand, to provide for the es- 
cape of morbid material which may be developed in wounds. To 
prevent the entrance of septic germs perfect cleanhness of every- 
thing which pertains to the operation is necessary. The carbolic- 
acid spray can at most only disinfect the air in the operating-room, 
and consequently it is only one fraction of the antiseptic method of 
operating. Clean operators and assistants, clean instruments, sponges 
and everything which may directly or indirectly come in contact 
with the patient before, during, and after the operation, are all of the 
highest importance. Still more, it is absolutely necessary to keep 
all things clean during the operation. A clean, fair start may be 
made ; but during the operation the operator's hands and the instru- 
ments may become contaminated by contact with the contents of 
the cyst, and the patient be exposed to septicaemia. This has often 
occurred when the spray has been thoroughly and faithfully used. 
Indeed, if too much dependence is placed upon the spray, there is 
great danger of contamination from want of care in other respects. 
Some of the fluid contents of the cyst may enter the abdominal cav- 
ity, or the hands of the operator or his assistants may become soiled 
from the same source, and mischief may be wrought in that way. 
In short, it is exceedingly difficult to guard against all sources of un- 
cleanliness in this complicated operation. I think, then, that if all 
the other essential elements of antiseptic surgery are carefully ob- 
served, the spray may be left out and still the highest success can be 
attained. But spray or no spray, too much can not be said in favor 
of antisepsis in relation to ovariotomy. 

There is still another fact which stands out prominently, and 



OVAKIOTOMY. 515 

upon which success depends, and that is the management of the dead 
material which may be unavoidably left in the abdominal cavity, or 
that may accumulate there after the operation. Blood or bloody 
serum or the contents of the cyst that may be left or may accumu- 
late in the peritoneal cavity is dangerous, and should be removed by 
drainage. 

It is true that within the last year or two there has been some 
difference of opinion regarding the value of drainage. Some of the 
great men in London have laid it aside as a rule, while Keith still 
employs it and insists that he saves many of his patients by it. 

I believe that I can see that those who employ drainage have the 
best of it. I incline to this view because Keith, who practices drain- 
age when necessary, has had the highest number of successes ; and 
because the reasoning against drainage by those who have given it 
Lip does not appear to fully harmonize with the facts in the case. 
It is claimed that if ovariotomy is performed with all the attendant 
means of antiseptic surgery, including the spray, any fluid which 
may be left or that may accutnulate in the peritoneal cavity is harm- 
less. Spencer Wells states that fluids do not accumulate after the 
use of antiseptics, or if they do collect they do not putrefy, but are 
absorbed without injury. 

N^ow it is difficult to understand how antiseptics used in the 
operation could prevent the accumulation of serum in cases where 
there were many and extensive adhesions, and, on the other hand, it 
is equally incomprehensible that carbolic acid in sufficient quantity 
should remain in the abdominal cavity to disinfect the fluids which 
transude from broken surfaces. Without daring to decide the 
matter or to express any positive opinions, I may state that the 
truth appears to me to be this : Antiseptic operating will lessen the 
danger to a very great degree, but there will always be cases which 
call for drainage. 

The value of drainage depends largely upon the mode of using 
it. The method which I have usually seen practiced in this country 
is to pass a tube through the lower angle of the wound down into 
the sac of Douglas, and then to close its outer end with a cork. 
This cork is removed several times a day, and the fluid pumped out. 
This gives a kind of intermittent drainage which is very imperfect. 
The method which I obtained from Dr. Keith is much better. In 
place of closing the end of the tube he passes it through the center 
of a piece of rubber cloth, and then places a carbolized sponge upon 
the end of the tube. The rubber cloth is folded over the sponge, 
and tied securely with a string. The tube and the sponge are thus 



516 DISEASES OF WOMEN". 

excluded from the air, and any fluid which accumulates wells up 
through the tube, and is taken up by the sponge. The sponge is 
changed several times a day, and any residual fluid which may re- 
main is pumped out at each dressing. In this way continuous drain- 
age is kept up, and still a perfectly antiseptic dressing is maintained. 
This may appear to be a simple matter, but it constitutes the differ- 
ence between perfect and imperfect drainage. In a case operated 
upon last summer, I obtained twelve ounces of fluid in thirty-six 
hours by this method of drainage, and the temperature of the pa- 
tient never rose above normal, excepting one day when it reached 
one hundred, and remained there for a few hours. This case alone 
would be suj0&cient to demonstrate both the safety and value of 
drainage. 

In addition to the requisite skill in diagnosticating ovarian tu- 
mors, it is highly essential to success to make a connect estimate of 
the patient's general condition before operating. 

Preparatory Treatment for Laparotomy. — One meets not infre- 
quently with urgent cases which must be taken as tliey are and 
operated upon at once. The majority of cases, however, can be 
kept under observation long enough to obtain a clear idea of their 
characteristics. When the diagnosis of the local condition is made, 
the general state of the patient should be carefully examined into. 
The advantage accruing from acting on this principle was recently 
impressed upon my mind in a case of a large fibro-cystoma of the 
uterus which required removal While under preparatory treat- 
ment the patient's temperature rose to 103|-° F., and there was much 
pain in the abdomen. Septic peritonitis was suspected, but the 
temperature came down and again went up, showing that the trouble 
was a zymotic one, and it yielded promptly to the use of quinine. 
Had I operated without knowing that the patient was disposed to 
this form of fever, I doubt if she would have recovered as promptly 
as she did. 

The Nervous System. — The state or condition of the nervous 
system should be investigated, and, if found defective, should be cor- 
rected as far as possible. Many patients leave home to be under tlie 
care of the special surgeon, and this, together with the dread of the 
treatment, often deranges the nervous system. All this can be over- 
come, usually, while other preparatory treatment is instituted. Time 
should be given for the patient to become accustomed to her sur- 
roundings and to gain confidence in the nurse and surgeon. Dur- 
ing this time the true state of her nervous system can be ascertained. 
If she is sleepless and depressed, relief should be given by nerve 



OYAEIOTOMY. 517 

sedatives and tonics. Quite often tlie damaged state of the nervous 
system is due to impaired nutrition, and will be relieved by improv- 
ing the digestion. Occasionally the nervous trouble is primary, and 
requires direct attention. Opium in small doses is most reliable in 
producing sleep and relieving depression, but it deranges digestion 
and nutrition in some cases, and on that account other remedies 
should be employed. Sulphonal does remarkably well as a sleep- 
producer, and is much preferable to bromide, chloral, or any com- 
bination of these remedies. It produces the desired result in the 
great majority of cases that are not kept from sleep by severe pain. 
This remedy is worthy of note as rather new, and is certainly one 
that will cause sleep with no other perceptible effect, good or bad. 

To restless, anxious patients, who lind the days very long even 
when they sleep at night, and on whom opium does not act well, 
I have given large doses of lupulin and small doses of cannabis 
Indica. If these do not answer, opium should be tried. 

One of the greatest advantages of this preparatory treatment is 
that the effect of opium on the case in hand can be observed, so that, 
if it becomes necessary to use it in the after-treatment, the surgeon 
knows how far to depend upon it and what effects may be expected. 

The Nutritive System. — This requires attention in all patients. 
In the majority, nutrition is impaired because of derangement of the 
digestive organs. In others the general nutrition is good, while the 
digestive organs alone are at fault. 

The time during which the trouble calling for surgical treat- 
ment has existed makes the difference in the general condition of 
the patients. 

There are tw^o classes of patients usually met in practice who re- 
quire attention in regard to digestion and general nutrition : First, 
those who have not been long under the influence of the affection, 
and need very little treatment, except, perhaps, to relieve consti- 
pation and subacute indigestion Such cases are often left with- 
out any preparatory treatment save a cathartic the day before the 
operation. This may be safe enough, but in the majority of cases 
the tongue is coated, the bowels sluggish, the appetite variable, and 
the kidneys act imperfectly. These conditions can all be relieved 
by a few small doses of the mild chloride of mercury, followed by a 
saline laxative. If this does not clear the tongue, improve the state 
of the stomacli, and increase the action of the kidneys, the treatment 
should be repeated in a few days. Second, the more advanced cases, 
in which there is general mal-nutrition as well as impaired digestion. 
These require more care and for a longer time. It sounds well to 



518 DISEASES OF WOMEN". 

say of sucli patients tliat the cause being the neoplasm, if this is re- 
moved the mal-niitritionwill be cured; but the chance of the patient 
being able to stand the operation may be improved by overcoming 
the constitutional derangements as far as that is possible. Gas- 
tric sedatives, such as bismuth or cerium, may relieve the irritation 
and improve the appetite, and tonic laxatives, such as nux vomica, 
belladonna, and rhubarb, will relieve constipation far better than 
salines. 

Management of the Bowels. — The objects in view in the man- 
agement of the bowels are threefold : First, to clear out the canal ; 
second, to establish as far as possible normal secretion ; and, third, 
to remove the causes of flatulence, whatever they may be. A 
cathartic should be given two days before the operation. In the 
choice of a laxative or cathartic, one should be sought which will 
meet all these indications. In cases showing deranged secretion, in- 
dicated by the state of the tongue and appetite, an alterative dose of 
mercury should precede the cathartic, as already suggested. The 
mercury, being a reliable disinfectant, will also meet another indica- 
tion, the relief of flatulence. The selection of a cathartic to be given 
just before the operation is important. Castor oil is the best in case 
there is constipation or a suspicion of faecal impaction. The only 
difficulty is that many patients strongly object to it. When it can be 
taken, it should be given two nights before the operation. This 
gives time for the oil to act, and also gives the bowels a chance to be- 
come quiet. The rectum should be washed out the night before the 
operation or early in the morning. In feeble patients who require 
a cathartic and yet are not strong enough to stand its operation, I 
give half an ounce of castor oil and two drachms of oil of turpen- 
tine. This is a most valuable preparation, if the stomach will retain 
it. In fact, this is the only cathartic that will act thoroughly in 
weak, debilitated patients without causing depression. The dose of 
turpentine is large, but if less is given it ^dll affect the kidneys and 
fail as a cathartic to some extent. This may be called a tonic or 
stimulant and cathartic. A similar effect may be obtained by giving 
six grains of rhubarb, one grain of compound extract of colocynth, 
one grain of camphor, and a tenth of a grain of extract of bella- 
donna, in pills. There is a little depression following the action of 
this, but it is not so certain in its action as oil and turpentine. 

To those who can not take either oil or pills without having their 
stomachs upset, I give one or two teaspoonfuls of calcined magnesia 
and half a teaspoonful of charcoal, followed in a few minutes, with a 
glass of warm lemonade. This empties the bowels and relieves flatu- 



OVARIOTOMY. 519 

lence very tliorouglily. This is given in the morning of the day 
before the operation, the object being to have the bowels quiet and 
empty at the time of operating. 

The condition of the heart and kidneys sliould be carefully no- 
ticed, especially that of the kidneys. The urine should be thorough- 
ly examined before giving an ansesthetic. I am satisfied that disease 
of the kidneys is the most important of the contra-indications to the 
use of anaesthetics. If any renal disease is found, it should be care- 
fully treated and watched, and, if it proves to be acute or subacute, 
sufficient relief can in time be obtained to warrant the operation ; 
but chloroform miglit be chosen in place of ether as the anaesthetic, 
and extra efforts should be made to shorten the time of operating. 
I have for a long time made it a rule to examine the urine always 
before giving an anaesthetic, and believe that it should be the invari- 
able practice to do so. I refer to that matter here because I have 
found many who do not think it necessary. 

In regard to the state of the heart, I find' that it is often de- 
ranged in its function from pressure or indigestion, and it nearly 
always improves under treatment. When there is time, I order 
muscular exercise as well as remedies to improve nutrition, and find 
that much improvement in the heart action follows. Organic heart 
disease, other than extreme hypertrophy, moderate dilatation, or 
aortic stenosis or insufficiency, does not deter me from giving an 
anaesthetic and operating. Many cases having disease of the mitral 
valve take ether very well. 

The day and evening before the operating day call for certain 
attentions. The bath so generally given the night precedins; the 
operation is not always advisable. If the patient is used to daily or 
frequent bathing it may be safe to give it, but otherwise it is dan- 
gerous. The patient may get cold or become exhausted. The bath- 
ing should be done, in such cases, several days before, and then with 
great care. When there is marked debility, with weak heart, digi- 
talis and nux vomica should be given the preceding day ; especially 
is this necessary when the operation promises to be a bad one. I 
formerly gave quinine, beheving that it was a good tonic and helped 
to prevent shock, but I am satisfied that digitalis and nux vomica 
are better. The number of doses should depend upon the effect. 
As soon as the heart action is noticeably improved the drugs should 
be withheld. 

The food should be of the most nourishing kind, and at the 
same time easily digested, or else it should be artificially digested. 
Sterilized or peptonized milk, clear soups, tender beef, mutton, eggs. 



518* DISEASES OF WOMEN. 

and raw oysters, either or all of these, according to the preference 
of the patient, may be used. 

The time to operate is, as a general rule, midway between the 
menstrual periods. An exception should be made in cases of menor- 
rhagia and dysmenorrhoea, in which there is an improvement in the 
strength toward the period of menstruation. Advantage should be 
taken of that temporary improvement by operating immediately be- 
fore the menses. 

The morning is by far the best time to operate. The patient is 
then at her best, and the stomach is empty — a condition very neces- 
sary to the taking of an anaesthetic. This would not be referred to 
here w^ere it not for the fact that a great many surgeons in this coun- 
try operate late in the day. There are many disadvantages in doing 
so. The patient sufiers from anxious anticipation, and becomes fa- 
tigued if food is not given ; and if it is given, it is not, as a rule, 
either digested or absorbed, and the stomach acts badly during and 
after the anaesthesia under such circumstances. 

I am led to dwell a moment on the general therapeutics of ab- 
dominal section, for the reason that my attention and that of my as- 
sistants has been so fully engrossed wdth the details of antisepsis and 
the technique of the operation, that many important items in the 
general therapeutics have been at times overlooked. It is likely 
that a similar experience may fall to the lot of others. 

There are certain points in the management of the patient dur- 
ing the operation which may be briefly mentioned. 

The patient should be kept warm, but the room should be cool, 
not over 70° F. A very warm room has been advised, and there 
are many surgeons who still prefer it, believing that there is dan- 
ger of chilling the patient by exposing the abdominal organs to cool 
air. This can be obviated in other ways, by keeping the patient's 
head and feet warm by hot water if need be, and protecting the 
trunk with rubber cloth. . Chilling the peritonaeum is avoided by 
the use of warm sponges. One large sponge should be placed in 
the wound as soon as the tumor is removed. This prevents the es- 
cape of the intestines, and protects the peritonaeum from the air. 
The sponges are maintained at the proper temperature by being kept 
in a pail which is placed in a larger one filled with hot water. The 
sponges are thus kept dry, while the water in the chamber around 
the inner pail keeps up the warmth. In case the operation is a 
long one, the water surroimding the sponge-pail can be renewed. 

"Warm ether is also of value in avoiding shock and chilling the 
patient. This is obtained by using my ether-inhaler, in which the 



OYAEIOTOMY. 



519* 



ether is vaporized in a reservoir and conveyed to the patient through 
a rubber tube. This warms the ether sufficiently to make it agree- 
able and safe. I have on former occasions spoken of the advantages 
of this ether-inhaler, by which the ansesthetic can be given pure, or 
diluted with pure air to any degree, and without the reinspiration 
of the expired air. I may add here that experience only tends to 
confirm my confidence in that method of using an anaesthetic such 
as sulphuric ether. 

List of Instruments and Appliances vsually required in the 
Operation. — Scalpel with fixed handle ; dissecting-forceps ; artery- 




Fig. 199. — Keith's short compression-forceps. 



forceps ; six Keith's compression-forceps (Figs. 199 and 200) ; one 
vulcellum forceps ; one fenestrated forceps ; small, straight, blimt- 
pointed scissors ; large, straight scissors ; trocar and rubber tube. 




Keith's long compression-forceps. 



These are placed together in an enameled pan filled half -full with 
a one-to-forty carbolic-acid solution. 

Twelve to twenty sponges, the exact mimber to he carefulkj noted, 
prepared and placed in a double tin pail with hot water in the outer 
compartment ; six towels soaked in a one-to-twenty carbolic solution, 
and put in the sponge pail ; No. 1, 3, and 11 prepared silk for liga- 
tures. 

These should be cut the proper length for ligating thick adhe- 
sions and the pedicle, and wrapped in gauze and put into the car- 
bolic solution. 

No. 4 silk for the abdominal sutures should be prepared in the 
same way ; No. 2 catgut ligatures ; Keith's needles, two for each ab- 



520 



DISEASES OF WOMEN". 



dominal suture (Fig. 201); Peaslee's needles; Keith's fine forceps 
for carrying the ligatures (Fig. 202) through the pedicle ; sutures to 

— I - ■ — rnT* 

Fig. 201.— Keith's needle. 

be used with Peaslee's needle if required ; a sheet of rubber cloth, 
three by four feet, with an oval hole in the center, the border of 




Fig. 202, — Keith's ligature forceps. 

which is coated with sticking-plaster an inch wide all around ; long 
straps of saddle-girth to fasten the patient's limbs to the table ; a yard 
of gauze or cheese-cloth soaked in a solution of one part of carbolic 
acid to eight of glycerin for a dressing ; sheet of absorbent cotton 
large enough to cover the abdomen ; flannel bandage ; safety-pins. 

Instruments and Appliances that may he needed. — Cautery 
clamps ; cautery irons ; Keith's clamp (Fig. 203) ; curved scissors ; 




Fig. 203. — Keith's modification of Spencer Wells's clamp. 

concave mirror ; counter-pressure instrument for tying ligatures in 
abdominal cavity ; several drainage-tubes of different sizes ; piece of 
sheet-rubber, ten by ten inches, to cover the end of the drainage- 
tubes ; twelve or more extra sponges ; twelve to twenty extra com- 
pression-forceps ; aspirator ; elastic ligature. 

These should be clean and placed within reach of the operator, 
but not mixed with the other instruments named. 

The instruments to be used should be placed on a stand beside 
the operator, and also a basin with carbolic solution, or such disin- 
fectant as the surgeon chooses to use for keeping the hands clean. 



OVARIOTOMY. 



521 



Tlie sponges, ligatures, towels, and dressings may be placed beside 
the tirst assistant 

Assistants. — Three assistants are certainly needed, and one more 
may be reqnired. One gives the ether, one stands on the left side 
of the patient, facing the operator, the third on the left of the op- 
erator, and the fourth one attends to the washing of the sponges. 

The chief assistant on the opposite side of the table sponges the 
wound during the incision of the abdominal walls, holds the vessels 
or adhesions when the operator is ligating them, supports the cyst 
when brought out, helps to apply the sutures to the wound, and ful- 
fills all orders of the operator. The second assistant supports the 
abdomen and cyst or tumor while the abdominal walls are being 
opened, and, when the cyst is being removed, he helps to expel it 
by pressure, and at the same time prevents the escape of the ab- 
dominal viscera. 

The assistants carry the patient from the bed to the table. A 
blanket is wrapped around her limbs, and a rubber bag of hot water 




rcjteiigi 



^PIRATOR| 



TUB FOR CYST-FLU 




m 



[etherizerI 



-^^LlGHf 



^SECOND? ||;0PERAT0R|| 

jTassistant I y^ ' 1) 

PTAND. WITH INSTRUMENTS AND BASINS^ 




Fig. 204. — Position of operator, assistants and accessories in the operation. Both arms 
should lie close to the patient's side. 

placed at her feet. The strap is passed over the thighs and around 
the table. The abdomen is made bare by opening the dressing-gown 
and raising the undergarment. The rubber cloth is spread over the 



622 DISEASES OF WOMEN. 

patient, and the edges of the opening in the center stuck fast to the 
skin around the lower and central portions of the abdomen. One of 
the carbolized towels is laid over the thighs of the patient, upon 
which are placed the instruments which are first to be used. This 
diagram will show at a glance the position of all concerned. 
The several steps of the operation are as follows : 

1. Making the incision in the abdominal wall. 

2. Exploring for adhesions. 

3. Tapping the cyst or cysts. 

4. Treating adhesions and removing tumor. 

5. Treating the pedicle. 

6. Examination and treatment of the other ovary. 

7. Cleansing the abdominal cavity. 

8. Closing the incision. 

9. Dressing the abdominal wound and placing the patient in bed. 
The details of the several steps in the operation in uncomplicated 

cases are as follows : 

The incision is made in the linea alba — traces of which can usu- 
ally be seen — down to the muscular layer. The length of the incis- 
ion should be about three inches, extending from one inch above 
the pubes upwards. The assistant should follow the knife with the 
sponge, and any bleeding vessels should be caught up in plain for- 
ceps. The tissues at the bottom of the wound should be picked up 
with a dissecting -forceps, and an opening made in the median line 
with the knife, the edge of which should be directed away from the 
tumor. When making this opening care should be taken to find 
the median line between the muscles. This is often done at the first 
trial, but, if the muscle is exposed, its sheath should be followed in 
either direction until the median line is found, and then another 
opening made there. The knife is then put aside, and one blade of 
the blunt-pointed scissors is introduced into the opening, and the 
incision completed by cutting in both directions. This usually ex- 
tends through the muscular layer ; the fascia and the peritonaeum 
still remain. These should be opened in the same manner. 

A sound, finger, or the whole hand may be introduced to de- 
termine the presence and character of adhesions, if such exist. The 
trocar and cannula are then plunged into the cyst at the highest end 
of the incision, the trocar drawn back and handed to the assistant, who 
takes care that fluid does not enter the abdominal cavity. The cyst- 
wall should be seized with a lock-forceps between the cannula and 
left side of the incision. This is also handed to the assistant, who 
holds it and the trocar in his left hand, and makes the necessary 



OVARIOTOMY. 528 

traction to withdraw the cjst, which he grasps with his right hand 
when it comes out, and holdo it without making traction upon the 
pedicle. 

The operator pushes a sponge into the wound behind the tumor. 
The pedicle is then examined to ascertain its size and character, and 
whether it be twisted. The cautery clamp (if that method of treat- 
ing the pedicle is to be practiced) is then applied, and the pedicle di- 
vided within half an inch of the clamp. The operator then sponges 
the abdominal cavity, taking special care not to leave any fluid be- 
tween the bladder and the uterus. The assistant meantime takes 
care of the clamp. The operator examines the other ovary, and 
decides whether it requires to be also removed or not. One or more 
sponges are left in the abdomen while the pedicle is being treated 
with the cautery. Two carbolized towels are placed under the clamp, 
and the remains of the pedicle are removed with the cautery. The 
clamp is then loosened a very little by unscrewing, and the cautery 
applied until the clamp is heated throughout to a degree that will 
admit of the linger being firmly placed upon it. Before finishing 
the cauterizing, the clamp should be screwed up tight. "While the 
cauterizing is being done, the assistant should remove all fluid and 
debris with a sponge and forceps, and, if the towels beneath the 
clamp become heated, they should be changed. The clamp should 
be cooled with a moist sponge without touching the cauterized edge. 
The pedicle is then seized with two forceps below the clamp, which 
is gradually and with great care loosened. The stump of the pedi- 
cle should be watched for a few seconds to see if the blood inclines 
to pass up any of the vessels in the part that has been cauterized. 
If there is no sign of such taking place, then the stump is dropped 
back and covered with intestines, and the omentum over all. Should 
the operator decide to ligate in place of using the cautery, the pedi- 
cle is secured by two compression-forceps, and a double ligature is 
passed through the center of the pedicle with a Keith's ligature- 
forceps, and ligated in two halves. Care should be taken to cross 
the ligatures, so that when the two are tied they wdll draw the tis- 
sues together in one mass. When the pedicle is small and long, 
it can be tied before cutting away the cyst, and without using a 
clamp at all. The sponges should be recounted at this stage of the 
operation, to make sure that none is left in the abdominal cavity — 
an accident w^hich has occasionally happened. 

A flat sponge is placed over the omentum and beneath the edges 
of the wound, and left there while the sutures are being introduced. 
All bleeding vessels in the abdominal wall should be lio-ated. Two 



52i DISEASES OF WOMEK 

Keith's needles are used for each suture, one at each end. The 
needles are introduced from the inside of the abdominal wall, and 
include the peritonaeum. This method of introducing the sutures 
is the quickest and the best when the incision is long or medium in 
length, but when the incision is short I prefer to use Peaslee's needle 
of smaller size than that which is usually found in the shops. The 
needle is passed from without inward, and the suture is carried 
through the double of the thread in the needle, and, as the needle 
is withdrawn, the suture is brought into place. Having introduced 
all the sutures, the ends on each side are gathered together and held 
while the flat sponge is removed. The air should be pressed out of 
the abdominal cavity, and the sutm-es tied. Slip-knots are prefera- 
ble. The sutures should be close together, about four to the inch. 
Here and there a superficial suture may be needed to make the co- 
aptation as complete as it should be. The dressing of gauze, soaked 
in the one-to-eight solution of glycerin and carbolic acid, is applied, 
and over that absorbent cotton and a flannel bandage. The patient 
is put into a warm bed, and hot water-bags or bottles put around 
her, and one sixth or one quarter of a grain of morphine given hypo- 
dermically. 

Complications. — The several steps in the operation are liable to 
be complicated by a variety of conditions. The chief of these may 
be mentioned in the order in which they come. 

AVhen there is much fat beneath the skin it is difficult to make 
a straight incision. In that condition the wall may be grasped in 
the left hand, raised up and transfixed with the bistoury and divided 
from within outward. This leads down at once to the muscular 
layer, and then the incision is finished in the usual way. Great 
vascularity of the abdominal wall, while easily managed, takes time. 
One or two bleeding vessels may be caught in plain forceps and con- 
trolled, but when there are many it is better to tie them because a 
number of compression-forceps are in the way during the operation. 

Firm adhesions of the tumor to the abdominal wall in the line of 
incision are often a troublesome complication, which leads the opera- 
tor either to open into the sac before knowing it, or else to sepa- 
rate the peritonseum from the abdominal walls. When the tumor 
can once be reached at any one point, it is very easy to separate the 
adhesions, but it is often difficult to get that one point. Enlarging 
the incision is a help, and it should be carried in the direction up or 
down according to the possibility of reaching a point where the cyst 
is free. Sometimes the exudation which forms the adhesion can be 
recognized when it is reached ; it is then easy to follow it up until 



OVARIOTOMY. 525 

the detachment is complete. When the cyst is exposed all the par- 
ietal adhesions should be loosened. This should be done bj the 
hand. When the tumor has been of slow growth and is tense and 
the walls opparentlj thick and strong, a very great amount of force 
can be used in separating adhesions. 

If the tumor is flaccid it is well to steady it with a pair of for- 
ceps while separating the adhesions and before introducing the 
trocar. 

Parietal adhesions are treated before tapping the cyst, at least as 
far as they can be easily reached by the hand. 



EMPTYING THE TUMOR IN COMPLICATED CASES. 

In multiple cyst and m unilocular cases in which the contents 
of the sac can be removed by tapping, the trocar and cannula are 
thrust into the nearest cyst and it is emptied in the usual way ; the 
trocar is then pushed into another sac, which in turn is emptied, 
and so on, until all are emptied. To do this safely the tumor should 
be steadied with the left hand, while the trocar is used with the 
right, and this helps to make sure that the trocar goes into the sac 
and not into the viscera or abdominal walls. 

When the contents of the tumor are semi-solid and wdll not flow 
through the cannula, the trocar and cannula should be removed, 
and the opening in the sac enlarged in the axis of the body ; i. e., 
the opening should correspond to the opening in the abdominal 
wall. A pair of forceps should be fastened near each end of the 
opening on the left side, and perhaps a small one at the lower end 
on the right side. These forceps are held by the assistant, and as 
the tumor becomes smaller he draws the sac out and down until 
the opening in the sac is below the level of the opening in the 
abdomen. The operator introduces his hand through this large 
opening into the cyst that is emptied, and breaks down the other 
cyst-walls and sweeps them out ; while the finger of the right hand 
is boring through the cyst- walls the tumor is steadied ^vith the left 
hand on the abdominal w^all. In this way the contents of large tu- 
mors may be broken down and removed. While this is being done 
the edges of the rubber cloth should be raised so as to direct tlie 
fluid into the tub or basin at the side. 

When the tumor is very vascular and great bleeding is likely to 
occur in emptying the contents, the pedicle should be found if pos- 
sible and compressed with catch-forceps. 

Adhesion of the omentum and the abdominal and pelvic viscera 



526 DISEASES OF WOME^. 

is treated after the tumor is emptied of its fluid contents. The 
omental adhesions are most easily tied while attached to the tumor, 
and that should be the rule, but if it is necessary to get the omen- 
tum out of the way before the operator has time to tie it properly, 
compression-forceps may be put on, and the whole wrapped up in a 
carbolized towel, and left on the abdomen at the upper angle of the 
wound until the cyst is removed, when attention can be given it. 
It should then be tied in sections of about the width of two fin- 
gers. 

Dr. Keith treats adhesions to the bowels and mesentery by mak- 
ing traction upon the cyst and pressing against the adhesions with a 
sponge. In this way the adherent tissues can be pushed apart with 
less injury than in any other way. Pulling upon adhesions should 
always be avoided, if possible. Sometimes when there are many ad- 
hesions high up strong traction must be made, there being no other 
way of separating the firm adhesions, but it is a dangerous practice 
and only to be resorted to when it can not be avoided. Long bands 
of adhesions should be tied before being detached, and the following 
points should be observed ; to have no tension upon these parts ; to 
ligate as far from the free end as possible, and make sure that all 
bleeding is stopped before letting go the parts. The bleeding which 
comes from the broad adherent surfaces which have been separated, 
should be controlled by placing sponges in the abdomen and making 
pressure, and as soon as possible bleeding points should be looked 
for and the vessels ligated. When the sponges are removed the 
position of the bleeding vessels can be seen. When there are many 
adhesions high up in the abdomen, it is an advantage to find the 
pedicle, clamp it with two spring catch-forceps, and divide it, and 
then remove the tumor from the pelvis first. When the adhesions 
are all treated and the tumor removed, the sponges which have been 
introduced should be removed, and the bleeding vessels caught up 
and tied. During this search for bleeding vessels in the pelvis the 
assistant holds the side of the abdominal wound with his left hand, 
and with a concave mirror in his right throws light into the pelvis. 
In using the mirror the assistant directs it so that he himself can see, 
knowing that if he can see the operator will see also. The artificial 
hght is to be used as little as possible, because if once begun it is 
difficult afterward to do mthout it. 

Drainage should be employed when from the number of adhe- 
sions there is seen to be a free transudation of serum ; when all the 
bleeding has not been or can not be stopped, and when either of the 
above conditions are present even in a very limited degree and the 



OVARIOTOMY. 527 

patient is feeble. The tube sliould be left in until the discharge 
becomes clear. 

When adhesions to. the intestines or pelvic organs are so firm 
and extensive that they can not be separated with safety, Dr. T. F. 
Miner, of Buffalo, enucleates the tumor or cyst from its peritoneal 
covering. This can be done, but it is often exceedingly difficult, 
and there is left a large surface from which a free transudation 
takes place, and requires long-continued drainage. This method is 
not practiced much now, except in cases of intrahgamentous cyst. 

When adhesions are very extensive and firm there usually has 
been inflammation of the cyst, and then its layers can not be sepa- 
rated ; this renders enucleation impossible. 

Treatment by Drainage answers in such cases if the cyst is small 
or of medium size. If the cyst is adherent to the abdominal wall it 
is laid open without being separated and its cavity thoroughly 
cleaned out, and a drainage-tube introduced, and kept in place. The 
sac is washed out frequently, and when it has contracted down it 
may be induced to close by the use of tincture of iodine and car- 
bolic acid. When not adherent to the abdominal wall, but so gen- 
erally adherent to the viscera that exploration is deemed impossible, 
the free portion of the sac should be trimmed off and its edges care- 
fully united to the incision in the abdominal wall, and then the 
drainage practiced. 

I am aware that an experienced and dexterous operator can man- 
age very bad adhesions, but there are cases where it is safer to use 
drainage. Five cases have been treated in this way in my own prac- 
tice, and four of them recovered. In the fifth, a bad case of rupt- 
ured cyst in which there had been very general peritonitis, the 
cyst was adherent everywhere. I could not find a single free spot, 
and the patient was very feeble. The sac was filled with inflamma- 
tory products, which were carefully cleared out, and large drainage- 
tubes used. She improved for a time and took food better than she 
had done before, but died at the end of a week, apparently from 
uraemia ; the kidneys were found to be diseased. 

In case of very intimate adhesions to the liver, spleen, uterus, 
bladder, or intestines. Dr. W. L. Atlee did not detach them at all, 
but separated the peritoneal from the middle coat of the cyst at the 
point of attachment, and left it there. This also is not often neces- 
sary, but it may be the easiest and safest thing to do, and if drain- 
age is employed good results may be expected. In this I have had 
no experience. 

Arrest of Hsemorrhage. — All adhesions in the form of bands ex- 



528 DISEASES OF WOMEN". 

tending from the cyst to other parts should be tied before dividing 
them. This applies especially to adhesions of the omentum. 
Large bands should be tied with prepared silk ligatures. The liner 
bands may be tied with catgut. In my own practice I use silk alto- 
gether. Intimate adliesions which have to be separated by trac- 
tion leave bleeding surfaces, and if any large vessels are found they 
should be tied if possible. General oozing can usually be stopped 
by pressure with a sponge. Hsemorrhage deep down in the pelvis 
from vessels large enough to be ligated can be reached by throwing 
in the light from the mirror and using a long artery-forceps. The 
ligature can be easily tied by using the counter-pressure instrument 
euGployed in tying the sutures in the operation for restoration of the 
cervix uteri. 

To check oozing from surfaces like the uterus, liver, or spleen, 
pressure with sponges is to be performed as stated already. An 
application of persulphate of iron is made by some operators, and 
the thermo-cautery has also been commended. Both are objection- 
able, and should be avoided if possible. 

After-Treatment. — The bed in which the patient is placed should 
be warmed to about the normal surface temperature. The patient's 
head should be covered with a soft woolen shawl or soft blanket. 
The hands should be kept under the bed-covers and not disturbed. 
The pulse should be watched at the temporal artery. A hot-water 
bag may be placed near the feet, but not in contact with them. I 
have repeatedly seen the feet burned by placing a hot-water bag 
close to the skin. This will not occur when the bag is wrapped in 
flannel. The air in the room should be kept at about 70° F., and 
ventilation secured without having the patient in a draught. For 
a number of hours ether is thrown off with the expired air, and it 
is difficult to keep the air in the room agreeable. It is fortunate if 
the patient sleeps after the operation, and no effort should be made 
to awaken her, as is frequently done, to find out how she feels. 

During the first twenty-four hours or more, the greater the 
amount of rest that can be obtained the better. Absolutely noth- 
ing should be given in the way of food or medicine unless there is 
some urgent demand for either. ^Nausea and vomiting, which occa- 
sionally occur, should be counteracted with sips of hot water if the 
patient is anxious to have something to drink — not otherwise. 

Keith usually gives a hypodermic dose of morphine immediately 
after the operation, to control the restlessness which supervenes 
when the patients come out of the anaesthetic. This is not always 
necessary. I wait and see if there is much restlessness or pain, and 



OVARIOTOMY. 529 

if there is, the hypodermic is given. ISTervous restlessness alone can 
often be controlled by the efforts of a judicious, experienced nurse. 
If the patient can be controlled until night, it is better to withhold 
the morphine until then. 

This expectant treatment should be continued until the stomach 
has become reliable and gas has passed from the bowels. In many 
cases nothing else is required during the first forty-eight hours. I 
am sure that great harm is done by giving nourishment and medi- 
cines when there is no demand for either. I certainly have seen 
more harm come from doing too much at first than from doing too 
little. There are exceptions to this rule of doing nothing. In case 
the vomiting continues, and is not relieved by hot water, I use the 
following : Magnesise carb., 3 ij ; magnesiae sulph., 3 iij ; aquae menth. 
pip., § iij. Of this, a teaspoonful may be given every one, two, or 
three hours in a dessertspoonful of water. This prescription is used 
in the Samaritan Hospital in London. A mustard plaster to the pit 
of the stomach is also useful. 

When these remedies fail, and the patient complains of burning 
in the stomach, dessertspoonful doses of iced water may be used. 
When the patient is depressed, ten drops of whisky in a teaspoonful 
of water every few minutes will be of service. In desperate cases I 
have given a large quantity, as much as the patient could drink, of 
lukewarm water and a little table salt. This is thrown oif promptly, 
and sometimes gives relief. It should not be repeated. If relief is 
obtained and the nausea returns, the stomach should be washed out 
in the usual way. 

When the vomiting is attended with abdominal pain, morphine 
hypodermically will give relief in many cases. 

Peritonitis and Septicaemia after Laparotomy. — From recent re- 
ports in the literature of medicine it appears that a new departure 
has been taken in the after-treatment of cases of ovariotomy and 
similar operations. In place of giving opium and keeping the 
bowels at rest for several days, the bowels are moved early, and 
opium is withheld. Cases which show signs of septicaemia or peri- 
tonitis are given saline cathartics. It is claimed that free action of 
the bowels effects a kind of drainage which arrests the tendency to 
inflammation of the peritonaeum, and also favors the elimination of 
septic material. One should gladly accept whatever theories or facts 
may be advanced in favor of this plan of treatment, or any other 
which might prove better than the old ways of managing such cases. 
But I have failed to see that this new treatment has many advantages. 

So far as I can learn, the results, on the whole, do not compare 



528* DISEASES OF WOMEN. 

well with those of other surgeons who give opium and let the bowels 
and the stomach rest, until the first dangers are past. Furthermore, 
I have found in my own practice that as soon as the indications for 
cathartics appear, it is impossible to have the patient retain them, in 
the great majority of cases. 

Perhaps the advocates of this treatment may be able to anticipate 
the coming storm, and, by giving salines, ward it off ; but I have not 
been lable to do so. 

While there are a number of reasons why opium should be used, 
I have not yet heard of any good reason why it should not be, in 
certain cases. 

That there are patients who do not need opium, and others with 
whom it does not agree, must be admitted ; but the majority require 
it to relieve pain, produce sleep, and, above all, rest and quiet, which 
are so very necessary to recovery after major operations. These 
effects of opium, it may be claimed, simply contribute to the comfort 
of the patient^ but do not secure safety or aid in recovery. Grant- 
ing that such may be the case, the humane surgeon will find in this 
good reason for the use of opium ; but I am confident that opium 
has a therapeutic value in addition to that of relieving suffering. 

The danger from shock which arises from major operations is, I 
am sure, controlled by opium better than by any other drug. So 
also is the depression from anaemia resulting from haemorrhage. 
All careful observers have noticed that the rapid and feeble pulse 
becomes fuller, slower, and steadier under the influence of opium. 
The anxious, pinched face also changes to a better expression. This 
has led me to look upon opium as the most reliable of all heart ton- 
ics in the depression which follows these operations. When the 
organic nervous system is tottering under the oppression of severe 
injuries to the abdominal and pelvic viscera, opium is the greatest 
sustaining agent. Alcohol, no doubt, will bridge over a moment of 
extreme and immediate danger, but its effects must almost always 
be supplemented with opium in order to obtain a continuous sus- 
taining effect. 

Perhaps more important still is the question, Does opium have 
the power of preventing peritonitis and septicaemia, or of controlling 
their fatal tendencies ? To judge fairly of the therapeutic effects of 
opium in surgery, it is necessary to keep in mind the fact that after 
an operation there are injured tissues left that must be repaired. 
These tissues may or may not be affected with septic material, but 
in either case the safety of the patient depends upon these wounded 
tissues being speedily closed in by reparative material, which re- 



OVARIOTOMY. 529* 

stores continuity of tissue and at the same time protects the normal 
surrounding tissue from inflammation and the patient from general 
septicaemia. Now this process, by which the general system is pro- 
tected from the dangerous effects of local injuries, requires time ; 
and it is the most important time, because upon completion of this 
protection depends the safety of the patient to a great extent. 
Wounds may do badly, but, if an exudation has been thrown around 
them which protects from septicaemia, recovery may be expected 
Of course, the modern surgeon protects his cases from sepsis by his 
cleanly operating ; but in spite of his best efforts there may be 
trouble occasionally, and then the great point is to gain time for 
this natural protective process, which comes, or should come, first 
in the order of restoration. The principal condition necessary to 
secure the protective factor in the general process of repair is re- 
pose or quietude of the nervous and circulatory systems, and opium 
is the most potential agent in efl'ecting this condition. The process 
of repair is arrested when the nervous system is in turmoil and the 
circulation is running wild, and opium should be used to give the 
necessary rest. It is a fatal mistake to wait until there is evidence 
of inflammation or septicaemia. It should be given to control the 
nervous excitation which generally precedes these complications. 

The time to give it, then, is an important question. Some of 
the most successful surgeons give it immediately after the operation, 
and that is best when the case i^ bad and there is shock. In easy 
cases I prefer to wait until the ether effects pass off to some extent ; 
and if there is distress or pain present, then is the time to give 
opium, and the effect should be kept up until there is no danger of 
complications, so far as the condition of the patient indicates. 

The way of giving it is of some importance, no doubt. I prefer 
to give it at first hypodermically, and keep up the effect in that 
way, or by rectal instillations of opium and warm water. 

The question which follows is, When shall the opium be with- 
df^wn, and cathartics resorted to ? Opium should be gradually 
given up as the constitutional and local evidences of disease sub- 
side, and then cathartics or laxatives should be given. To state 
this in another way : opium should only be given wiien there are 
indications for its use, and it should be given up as soon as the indi- 
cations disappear. The bowels should rest until the time for peri- 
tonitis is past, or, if there has been inflammation or sepsis, when the 
acute symptoms and signs of these have subsided. 



CHAPTEE XXIX. 

ILLUSTEATIYE CASES OF OVAEIAN NEOPLASMS. 

In giving the histories of ovarian neoplasms it has been deemed 
best to omit simple and typical cases, because they would add noth- 
ing to the description already given. The following complicated 
ones, on the other hand, will tend to convey clearer ideas of the 
peculiar cases which are frequently met in practice, and the approved 
methods of management adopted at the present time. 

Monocyst of the Right Ovary ; Firm Adhesions to the Ahdominal 
Wall ; Necrosis of the Posterior Wall of the Cyst ; Ovariotomy ; Re- 
covery. — The patient was lif ty-f our years old, and the mother of four 
children. After the birth of her last child, the attending physician 
told her that she had a small tumor on the right side of the uterus. 
There was considerable intermittent pain in the region of the neo- 
plasm from the time that it was fiist discovered up to the time that 
she came under the care of my associate. Dr. Palmer, four years 
afterward. The growth of the tumor was slow, scarcely noticeable 
for the first three years, but very noticeable during the last year. 

When she first came under the care of Dr. Palmer the tumor ex- 
tended above the umbilicus, and fluctuation was well marked. 
There was evidence of circumscribed peritonitis, and, although the 
tumor was movable, adhesions were being formed. The peritonitis 
was quite pronounced at this time, and the constitutional symptoms 
were well defined. She was treated for this, and in about two weeks 
the acute symptoms subsided, but she still remained weak. The 
doctor sent her home in the hope that she would gain strength, and 
the tumor being still small there was no urgent necessity for its re- 
moval. In a month she returned to the hospital not improved. 
She was losing flesh, the parts were still tender, the appetite poor, 
the pulse weak, and the temperature kept above 100° F. 

Another effort was made to get her into better general condition, 
but without success. She lost strength gradually, and it was de- 



ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 531 

cided that tlie only chance for her was by removing the tumor. At 
this time the adhesions were firm and involved all parts of the ab- 
dominal wall which were in contact with the tumor. 

Just before the operation the pulse was 120 and the temperature 
101°. When the abdominal incision was made, the adhesions were 
very firm and vascular, except in a small space just above the sym- 
phisis pubis. The cyst was emptied by tapping, and the lower por- 
tion, which was not adherent, was drawn out, and the pedicle grasped 
with strong fixation forceps, and divided. The adhesions were now 
easily reached and separated. The pedicle was then ligated, and the 
bleeding stopped by pressure with sponges. By managing the pedi- 
cle in this way, the tendency to bleeding from the site of adhesions 
was lessened very decidedly. When all bleeding had stopped the 
wound was closed and dressed in the usual way. 

An examination of the cyst showed a portion of its posterior 
wall (about the size of one's hand) perfectly bloodless, of a dirty 
gray color and friable, indicating that it was necrosed. 'No doubt 
the death of this portion of the sac had taken place many days be- 
fore the operation, and I presume was the cause of the constitutional 
disturbance. 

From the facts in this case and from those observed in other cases 
of necrosis of the cyst- wall, I believe that the dead tissue causes a 
form of septicaemia, certainly in this case there was nothing else 
found to cause the high temperature and pulse, and the subsequent 
history confirms this view. 

The operation was performed between eleven and twelve o'clock. 
She soon recovered from the ether, and showed no depression. At 
seven in the evening her condition was better than before the oper- 
ation. The pulse was 112, temperature 99*5° F. and respiration 20. 
During the night she had slight pain in the abdomen and was given 
a hypodermic injection of morphine. She slept well, and had 
no vomiting. On the second day there was some slight distention 
of the abdomen from gas ; this was relieved by six grains of sul- 
phate of quinia in solution, given by the rectum. 

From this time onward her progress was very satisfactory. The 
temperature never rose above 99° F. Five days after the opera- 
tion the bowels were moved by enema. On the twelfth day she 
left her bed, and four days later was able to walk about the ward. 
About four weeks after the operation the left leg became swollen, 
and remained so for about a week. The cause of this was not 
certain. 

She was discharged from the hospital at the end of the fifth 



532 DISEASES OF WOMEN. 

week feeling perfectly well and having gained flesli and strength 
surprisingly. 

Intraligamentous Ovarian Cystoma; Multiple Cyst of the other 
Ovary; Ovariotomy and Hysterectomy; Recovery.— Tins patient was 
under the care of my friend Dr. F. H. Stuart, and naost of the 
facts in the history of the case — before and after the operation — are 
given here as I obtained them from him. 

The lady was fifty-six years of age, and had passed the meno- 
pause about six years. At the age of thirty-nine years she had 
a pelvic abscess which opened into the bladder, and she was 
then sick for a long time. About three years before the time 
when this history was taken she noticed a tumor in the right iliac 
region. 

She was first seen by Dr. Stuart, April 30, 1886. He found 
the uterus high up behind the symphysis, attached to an elastic 
tumor, which was immovable, and by external examination appeared 
to be larger than a fetal head and extending up into the right iliac 
fossa. There were two other tumors of smaller size, one above 
and one to the left of the larger one. These appeared to be adher- 
ent to the first one, and were also rather immovable. I saw the 
patient the next day with the doctor, and confirmed the diagnosis of 
ovarian cysts. On account of the a'dhesions, and as the patient was 
not suffering any great inconvenience, we thought it best to await 
further developments. 

She passed a very comfortable summer, but increased steadily in 
size, with a corresponding increasing discomfort in locomotion. 
About the 1st of December, 1886, she began to have frequent and 
painful urination, and some fever. After a few days of quiet and 
some quinine (as there was a decided intermittence in the irritability 
of the bladder), she became again quite comfortable. 

Immediately before the operation the physical signs were as fol- 
lows : The general outlines of the enlarged abdomen were irregular, 
three cysts could be mapped out, and fluctuation was distinct in 
each. The most dependent cyst was about the size of the uterus at 
the seventh month of utero-gestation, and occupied the center and 
lower region of the abdomen. It was not movable to any extent, 
and appeared to be separated from the other cysts except at the up- 
per and right side, where it seemed to be adherent but not firmly 
so. The two other cysts occupied the upper and left lower regions 
of the abdomen, raising the diaphragm and causing the lower ribs to 
project slightly. These two cysts could be moved together in the 
abdomen, but were closely united forming one tumor. The fluctua- 



ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 533 

tion was very clear in eacli of them, but was not distinctly felt through 
the mass formed by the two. 

All around the circumference of the abdomen there was dull- 
ness on percussion, and distinct Huctuation, though broken at points 
where the divisions between the cysts were. These signs simply in- 
dicated the presence of a multiple cystic tumor. The umbilicus 
was high up, showing that the lower portion of the abdominal mus- 
cles was distended most, and in a space about live inches in diame- 
ter in the umbihcal region there was tympanitic resonance and 
gurgling on pressure, showing the presence of intestines at that 
point. Taken altogether the abdomen appeared to be occupied by 
a large cystic tumor with a mass of intestines in a cup-shaped space 
in its center. 

By vaginal touch the uterus w^as found displaced upward and 
forward, and the cervix could be reached without difficulty, owing 
to its being crowded toward the pubes. Behind the uterus and ex- 
tending down into the upper and posterior portion of the pelvis a 
segment of cyst was found. The uterus was displaced by moving 
the cyst in front, and pushed forward by raising the cyst behind it. 
The examination indicated very certainly that there was a cystic ova- 
rian tumor of the multiple variety, but there was evidently more 
than that. The fact that the uterus was involved raised the ques- 
tion of uterine hbro-cyst, as well as ovarian tumor, but there was 
some doubt about the nature of the whole mass. It was possible 
that the uterus was simply adherent to the cystic tumor, and that 
the adhesions had been formed while the tumor was still in the pel- 
vis, and the uterus had been carried upward as the tumor grew. It 
also was presumed that there might be two cystic tumors, and that 
the uterus was attached to one of these. 

While the exact pathological conditions were not decided upon, 
two facts were quite evident ; first, that there was at least an ovarian 
tumor, and that the patient must obtain relief, if at all, by ovariot- 
omy. 

Ojperation, — After making the abdominal incision, the first cyst 
was exposed, and adhesions of the omentum were found on the right 
side. The omentum was vascular and its adhesions covered the 
upper part of the tumor. After emptying the cyst by tapping, the 
omental adhesions were ligated and separated, and it w\is then found 
that this cyst had no connection wdth the cysts above, but was situated 
between the folds of the broad ligaments, and extended from one 
side of the pelvis to the other, between the uterus and the bladder. 
The uterus, being behind the cyst- wall and firmly attached to it, had 



534: DISEASES OF WOMEN. 

been stretched laterally so that its long diameter was transverse. 
The empty cyst was held outside of the abdominal wonnd at this 
stage of the operation by forceps, and the incision extended upward 
so that I conld reach the other tumor, which I found to be a multi- 
ple cyst of the left ovary. 

The four largest cysts were tapped separately, first the one on 
the right side, and next the one above and to the left, then the one 
that dipped down behind the cyst of the broad ligament and uterus, 
and lastly a middle one between the upper and lower cysts. There 
was a deep fissure between the two cysts on the left side through 
which the intestines found their way up to the abdominal wall, 
which accounted for the tympanitic resonance obtained during the 
examination. Tliis tumor had an ordinary pedicle starting from the 
left posterior surface of the broad ligament, which was ligated with 
silk, and the tumor removed. 

Having disposed of this tumor, I returned to the cyst of the 
broad ligaments, and upon laying it open and inspecting its cavity, I 
found at the bottom of it a papillomatous mass which had the ap- 
pearance of an epithelioma. 

I then undertook to enucleate this cyst, the lower portion of 
which was fixed in the broad ligaments, between the bladder and 
uterus, as already stated, but the adhesions were so firm and the 
vascularity so great, that this was impossible. I then tried to enu- 
cleate the inner wall of the cyst, but this was also impracticable. 
The thought occurred to me that I might stitch the cyst-walls to the 
sides of the incision in the abdominal walls, but as the cyst dipped 
down into the broad ligaments on both sides, tw^o pockets would 
have been left, which would have been difiicult to drain. The 
papillomatous mass in the central part of the sac would have been 
left also, and that, I presumed, would have interfered with the clos- 
ure of the sac, and the final recovery of the patient. 

It seemed as if the w^hole thing should be removed, but I could 
not take in all the tissue involved in any ordinary clamp. 

I then tied and divided the broad ligament on both sides from 
the outside toward the center, so as to form a pedicle which could 
be grasped in the clamp. The bladder was dissected from the cyst- 
wall far enough to let the clamp get down below the uterus and the 
most dependent portion of the sac. Keith's modification of Baker 
Brown's clamp was then applied, and the cyst and uterus removed. 

A drainage-tube was introduced above the clamp, and the abdom- 
inal wound closed from above downward. 

The operation was completed at noon, and five minims of Ma- 



ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 535 

gendie^s solution of morphine were given hypoclermicallj at once. 
She slept quietly for about two hours and then had some nausea, and 
Yomited a mouthful of mucus. The remainder of the day was passed 
comfortably, the catheter was used, and sips of hot water were given. 
At midnight the temperature was 99f ° and pulse 86. The second 
day was without much to note except that the temperature went up 
to lOlf ° but, toward midnight, it came down to 100° and the pulse 
was 86. There was some distention of the bowels which was relieved 
by quinine, given by the rectum. From this onward the patient 
did very well, the pulse was good and temperature ranged from 99° 
to 100°. She required morphine to keep her comfortable, but noth- 
ing more. 

After the operation the kidneys acted very well, the catheter be- 
ing used for two days, and after that the patient urinated without 
trouble and passed the usual quantity of water. On the tenth day, 
while urinating, the dressing of the wound became saturated with 
urine, showing that the upper part of the bladder had opened ; the 
dressings were removed, but the opening was covered by the clamp 
and could not be seen. Several times afterward when she urinated 
she passed a very small quantity of water by the urethra, the larger 
portion passing by the side of the clamp. Between the times when 
she urinated there was no leaking from the opening in the bladder. 
She was not permitted to urinate after this ; the catheter being used 
at regular intervals. 

For two days very little urine escaped from the opening, and 
then a little began to come, which made the wound unclean. 

It being quite evident that the stump, below the clamp, had un- 
dergone necrosis to a considerable extent, an elastic ligature was 
passed around the stump, below the clamp, in the hope that it would 
cut its way through the softened and dead tissues, and set the 
clamp at liberty ; it did so to a limited extent only, and, as it was 
very difficult to keep the wound clean, the clamp, on the fifteenth day 
after the operation, was carefully liberated by dividing the dead tissues 
of the stump with the knife and scissors. No haemorrhage was caused. 

When the clamp was removed, it was found that the necrosis of 
the tissue extended farthest on the right side, and it was at this point 
where the bladder was open. At first it was thought that the blad- 
der had been included in the clamp ; but that did not seem possible, 
because of the extreme care taken to avoid it when applying the 
clamp, and also from the entire absence of all functional disturlv 
ance of the bladder during the ten days immediately succeeding the 
operation. 



536 DISEASES OF WOMEN. 

After removing the clamp, and seeing how far the death of the 
tissues of the stump had extended on the right side, it appeared that 
the opening of the bladder was due to this destruction of the tissues. 
The opening occurred on the right (as has been already stated), at 
the site of the old cellulitis, which she had years ago, and where the 
abscess discharged into the bladder, in all probability, and this may 
account for the death of the tissue below the clamp. 

During the operation it was noticed that the right broad liga- 
ment was thickened greatly, and changed in appearance, owing no 
doubt to the products of the old inflammation, and the damaged state 
of the tissue probably favored the necrosis ; this may have been 
also favored by the pressure of the abdominal wall. The pedicle 
was broad, so that it stretched the wound, and the pressure of the 
strongly retracted edges of the wound may have helped to strangu- 
late the right side of the stump, the vitality of which was of a low 
order. 

The dressing of the stump and abdominal wound now became a 
rather diflScult task, owing to the escape of urine. Iodoform and 
absorbent cotton did best of all. Although the catheter was used, 
there still was some leaking above. The urethra became tender to 
the passing of the catheter, and then the doctor tried keeping it in 
the bladder continuously. This did well for a time, but had to be 
given up because of the pain caused. By the free use of cocaine 
the catheter could be used, so that the leaking in the wound was not 
great. During all this time her general condition was fairly good, 
but the wound healed slowly, and she needed morphine to keep 
her comfortable. 

About this time several of the ligatures used in tying the broad 
ligament on the right side came away through the wound. About 
Ave weeks after the operation, and while she was apparently well, 
except that the fistulous opening of the bladder remained and her 
strength had not returned fully, she was taken quite ill ; the tem- 
perature ran up to 103°, and the bowels became constipated ; the 
appetite was entirely lost, and she looked badly in the face, and lost 
flesh rapidly. 

There was a hard, irregular mass felt in the right side of the 
abdomen at this time, which was presumed to be a local inflamma- 
tion due to the ligatures used in ligating the omentum. The doctor 
and I were not without some fears that it might be the beginning 
of some malignant disease, but it proved not to be so. Quinine 
given by inunction and the rectum controlled the fever after a time, 
and then the stomach and bowels began to act again. 



ILLUSTRATIVE OASES OF OYAEIAN NEOPLASMS. 537 

From this time her progress was favorable, and she is now (one 
year after the operation) perfectly well. 

A Papillomatous Monocyst of the Ovary. Ovariotomy. Fatal 
Termination from Haemorrhage. — The patient was thirty-live years 
old. She had had two children. For about one year before the 
ovarian tumor was detected she suffered from monorrhagia. When 
I first saw her she was quite ansemic from long-continued and pro- 
fuse menstruation, caused by polypoid fungosities of the uterine 
mucosa. She was promptly relieved by curetting. At that time 
the ovarian cyst was about the size of a pregnant uterus at four and 
a half months. The cyst increased in size rather slowly. She had 
two attacks of circumscribed peritonitis, one at the upper part of 
the cyst, which gave rise to adhesions to the abdominal wall above 
and to the left of the umbilicus. About eight months from the 
time that I first saw her, and after the slight attacks of peritonitis, 
she was attacked with severe pain in the region of the cyst, but there 
was no evidence of inflammation. 

At this time the cyst became very tense, and there was general 
tenderness and heavy pressure. These symptoms subsided for a 
time, but there were several attacks of this kind, each one being 
marked by a sudden increase in the tension of the cyst. The patient 
continued to be rather anaemic, there were wandering, ill-defined 
pains in the abdomen, and the general condition showed that she suf- 
fered more than is usual in cases of uncomplicated ovarian cystoma. 

This led to the determination to operate, though the size of the 
cyst did not demand immediate interference. 

When the wall of the abdomen was opened, and the cyst exposed, 
it was darker in color than it should be ; adhesions were found at 
the upper and left side, and also low down and near the median line. 
Tapping was tried, but the contents of the cyst would not flow. The 
sac was then opened, and its contents were found to be blood and 
old blood-clots with very little ordinary ovarian fluid. It was neces- 
sary to pass the hand into the cyst to evacuate its contents ; this 
caused fresh and profuse bleeding. The patient showed the loss of 
blood very rapidly ; great haste was made to separate the adhesions, 
which were very vascular and required ligating. 

The depression became more and more marked, and it looked as 
if the patient would die on the table. The cyst was hurriedly re- 
moved, and the abdominal wall was closed. There was some oozing 
from the adhesions, and, as there was little time for sponging the 
peritoneal cavity and stopping the bleeding, which was only a very 
little oozing, a drainage-tube was used. The patient ralHed a little, 



538 DISEASES OF WOMEN. 

and there were hopes that she might be saved. There was consid- 
erable discharge of bloodj serum from the tube, which, in place of 
becoming less, as I expected it would, increased. Whenever the 
pulse improved, and the patient gained a little strength, the bleed- 
ing increased. It was never free enough to warrant my opening 
the abdomen to stop it, but kept on just enough to keep the patient 
down. At the end of the third day there was very little bleeding, 
and there was a promise of success, but then she began to show signs 
of heart-clot, and she died on the fourth day. 

The inside of the cyst was lined with a layer of papillomatous 
material, which presented a cauliflower appearance not unhke that 
of epithelioma of the cervix uteri. 

The points of greatest interest in the history of this case are the 
frequent hgemorrhages which took place in the cyst during its growth 
and the unsatisfactory character of the operation w^hich permitted 
the loss of so much blood. There is no doubt in my mind but that 
the attacks of distress and extreme and sudden distention of the sac 
were due to the haemorrhages in the cyst. This view of the matter 
was confirmed by the large number of blood-clots which were found 
during the operation. The evidence of these extra cystic haemor- 
rhages was so marked and peculiar that I am sure a diagnosis could 
be made with certainty in similar cases. This would be a great gain, 
because it would enable one to operate before the frequent losses of 
blood had w^eakened the patient, and while the cyst was small, and 
could be more easily removed — two advantages which would tend to 
the safety of the patient. 

There were several unfortunate incidents in the operation which 
could have been in part prevented had I had more experience in 
such cases. In the first place, when the patient was anaesthetized, 
the cyst was handled with considerable force for the purpose of de- 
termining the presence and extent of the adhesions. This, I am 
sure, started the bleeding, which might have been avoided. When 
the cyst was opened, and the active haemorrhage detected, I should 
have found the pedicle, and temporarily controlled it with com- 
pression-forceps. This would have saved much of the haemorrhage, 
and then I could have taken time to treat the adhesions properly. 

These facts, I believe, explain fully the failure in the case, and 
they throw much valuable hght on the diagnosis and treatment of 
this peculiar variety of ovarian neoplasm. 

Ovarian Cyst between the Folds of the Broad Ligament. Incom- 
plete Removal of the Cyst ; the Remaining Portion treated with Drain- 
age ; Recovery. — This lady was thirty-five years old, and had been 



ILLUSTRATIVE OASES OF OVARIAN NEOPLASMS. 539 

married nineteen years. Her general health had been fairly good, 
but she did not menstruate until she was nineteen years of age. 
The menstrual flow had always been scanty and of short duration, 
and she ne^er had been pregnant. 

These facts indicated that probably the sexual organs were im- 
perfectly developed. About one year before she came under my 
care she noticed a small tumor in the right side of the abdomen^ low 
down. It steadily increased in size, and then she lost flesh and 
strength, and sulfered from pain in the abdomen and back, and her 
appetite failed. When flrst seen by me she had a bronzed appear- 
ance, was feverish, and the pulse was fast and rather weak. She 
had the general appearance of one in the last stage of ovarian dropsy, 
and also cachectic. The tumor was about the size of the uterus at 
the seventh month of pregnancy. It was very hard, and fluctuation 
was very indistinct. Though not apparently adherent to the abdomi- 
nal wall the tumor was not at all movable. It was firmly fixed in 
the pelvis, and there was much tenderness. 

By the vaginal touch the hard tumor was found deep down in 
the pelvis, firmly fixed, and not the slightest fluctuation or elasticity 
could be detected. The uterus was pushed to the left and upward, 
so that it partly occupied the left iliac fossa. The irregularity of 
the surface of the tumor, as felt through the vagina, indicated that 
it was surrounded by the products of inflammation. 

The physical signs, as observed by the vaginal touch, were such 
as would indicate a uterine fibroid developed in the right broad liga- 
ment, but the character of the tumor, as felt in the abdomen, 
showed that it was a cyst. The question of fibro-cyst was then 
raised, but the history of the case was not in favor of this. While 
there was little doubt regarding the true nature of the tumor I fav- 
ored the diagnosis of ovarian cyst complicated by inflammation of 
the cyst- walls. 

The patient was placed under treatment in the hope of improving 
her digestion and general health, but beyond relieving her consti- 
pation and flatulence there was no real gain. Her pulse remained 
about 98, and her temperature fluctuated between 99° and 101°. 
During the few days that she was under observation the cyst became 
a little less tense so that fluctuation could be more surely made out. 

The chief points of interest in the operation were as follows. The 
tumor, easily and fully exposed by an incision three inches long 
through the abdominal walls, was adherent to the omentum over its 
entire anterior surface. The cyst was emptied by aspiration of its con- 
tents which contained pus and lymph. The omentum was ligated 
36 



54:0 DISEASES OF WOMEN". 

in sections with, silk, and detached from the cyst- wall. It was then 
found that the folds of the broad ligament covered the cyst com- 
pletely, and were so intimately blended with the walls of the cyst 
that they could not be separated to any extent. Careful and persist- 
ent efforts were made to enucleate the cyst, but in vain. The open- 
ing in the cyst was temporarily closed with forceps, and the left 
ovary looked for. It was found far over on the left side and con- 
tained several small cysts. It was removed in the usual way. The 
major portion of the cyst-walLs and broad ligament was then re- 
moved, and the larger vessels ligated to control hemorrhage. An- 
other effort was made to enucleate the remainder of the cyst-walls, 
but they extended so deep down into the pelvis and the tissues were 
80 exceedingly vascular and matted together by inflammatory prod- 
ucts that it could not be done. The remains of the ligament and 
cyst-walls were carefuUy stitched to the abdominal wound, the sac 
carefully sponged clean, and a large drainage tube introduced. 

The after-treatment and progress of the case were as follows : 
She had for the first two days considerable nausea and pain. For 
this she was given hypodermic injections of morphine. The sac 
was washed out thoroughly every four or eight hours according to 
her temperature. There was not much nourishment taken during 
the first six days. The pulse and temperature varied greatly. The 
pulse kept above one hundred most of the time, and the temperature 
fluctuated between 100° and 102° and occasionally 103°, but this 
high temperature never lasted long at a time. 

During the first ten days the morphine was required, and stimu- 
lants had to be used. In spite of the frequent washing out of the 
sac and free drainage there was some blood-poisoning. Quinine 
was freely given (whenever the temperature went up) by the rec- 
tum and by inunction. From the twelfth day onward there was not 
much of interest. The patient's nutrition was poor, the pulse and 
temperature kept a little above normal, and occasionally the temper- 
ature rose to 101°, rarely to 102°. The sac cavity gradually dimin- 
ished, and the discharge became less. At the end of the third week 
the temperature was normal and remained so afterward. She took 
food weU, and began to gain strength and flesh. The cavity was 
very small, and the di-ainage-tube used was a piece of a Xo. 10 elas- 
tic catheter. The wound had completely healed, except where the 
tube was in place, at the end of the fourth week. 

Five weeks after the operation, and when the patient was up 
and apparently about well, there came a swelling quite hard at the 
side of the sinus, and the temperature went up to 102°. It was sus- 



ILLUSTKATIVE CASES OF OVARIA^ST NEOPLASMS 541 

pected that an abscess ^SbS, formiDg there, and in the hope of reach- 
ing it, if suppuration occurred, the opening was enlarged, and a 
tube of greater cahber introduced, but the swelling entirely subsided 
and the tube was removed. 

The patient was discharged in good condition two months after 
the operation, 

A Medium-sized Ovarian Cyst which could not be removed owing to 
the Character of the Adhesions ; treated by Drainage ; Recovery. — 
The patient, a German lady, thirty-four years of age, was admitted 
to the hospital, and gave the following history : She had had 
several children and had noticed a " lump " in the abdomen about 
one year before my first examination. This gradually but slowly 
increased, and at times there was pain but not severe, until about 
four months after she discovered the tumor. At that time she 
was seized with violent pain in the abdomen, especially on the 
right side. According to the history she evidently had at that time 
a severe inflammation. This slowly subsided under the care of her 
family physician, but she did not regain her health, and continued 
to lose flesh, her bowels were constipated, and there was much pain 
and tenderness in the region of the tumor. The size of the tumor 
increased, and it was much more prominent on the right side. 

At my first examination, I found the tumor firmly fixed on the 
right side, the adhesions to the abdominal walls and viscera being 
evident at all points, especially high up in the lumbar region on the 
right side. The fluctuation though not clear, was sufticiently so to 
indicate that the tumor was a monocyst. 

Her general condition was very poor, she was greatly emaciated, 
her skin was bronzed, and she had the general appearance of one 
suffering from malignant disease. Her pulse was feeble, and her 
temperature varied between 98° and 100°. She had pain and tender- 
ness in the abdomen, especially on moving. 

Efforts were made to improve the general health, but "without 
effect. The points of special interest in the surgical treatment were 
the following : The abdominal wall at the point of incision was very 
vascular, and the adhesions were also thick and vascular, and were 
with difliculty separated from the cyst-wall. On tapping the sac it 
was found that the contents contained lymph and sojne pus, show- 
ing that there had been inflammation of the interior wall of the cyst. 
On the left side the abdominal wall was separated sufficiently to en- 
able me to pass my fingers into the peritoneal ca\dty, and there I 
found the intestines adherent to the cyst-wall. I tried first to sepa- 
rate the adhesions but that could only be done by dissection, and the 



542 DISEASES OF WOMEX. 

bleeding was such tliat I had to abandon that procedure. I then tried 
to dissect the peritonaeum off from the cjst-wall and leave it attached 
to the intestines, but this was impossible. In a dissection about an 
inch long and half an inch in width I had to use three ligatures to 
stop the bleeding. I also found that every portion of the sac was 
fastened in by strong and vascular adhesions which I knew I could 
not separate without losing my feeble patient. The fact is I could 
not remove any considerable portion of the sac, only a very small 
portion in front. I thoroughly cleaned out the sac, and stitched the 
edges to the abdominal wall. This was easily done because the cyst 
was adherent all round to the abdominal wall, except on the left side. 
A large drainage-tube was introduced and the sac washed out with 
carbolized water twice or three times a day. 

The patient did well. She began to gain soon after the opera- 
tion, and continued to increase in strength slowly, but without in- 
terruption ; at the end of two weeks after the operation the sac had 
contracted very much, and there was considerable suppuration. The 
long tube was removed, and a shorter one was used to maintain the 
opening in the abdominal wall. The thorough washing out was kept 
up, and about live times in all I distended the sac with equal parts 
of carbolic acid and tincture of iodine. This destroys the secreting 
surface of the sac, suppuration followed, and the sac contracted grad- 
ually. At the end of two months there was little more left than a 
solid mass with a narrow and not very deep sinus in it. The patient 
was sent home, and directed to wash out the sinus daily. 

She was not seen again until five years after, when she returned 
to the hospital to see my associate Dr. Palmer. She had greatly 
improved in appearance, and stated that she had been quite well, 
and had attended to her household duties since she left the hospital 
after the operation. The opening in the sac remained for four 
months after she went home, but finally closed altogether, and gave 
no trouble afterward. She had a ventral hernia, which appeared at 
the point of the wound two years after the operation. 

I am satisfied that in certain cases in which the adhesions are 
extensive and very vascular that it is safer to leave the operation 
uncompleted, and employ drainage. 

I have had five successful cases treated in this way, and one very 
bad case that proved fatal, but probably would have recovered had 
the patient not had organic disease of the kidneys, of which she died. 
Mature judgment, based upon experience alone, can enable one to de- 
termine when to employ drainage in place of removal of the tumor. 
The only way to determine this is to examine the extent of the 



ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 543 

adhesions, and whether or not they can be separated without injury 
to the abdominal viscera. Should the cyst prove unmanageable by 
the operator, the part of it which can not be removed should be left 
and treated by drainage, and washed out with antiseptics. I am 
well aware that an expert and experienced operator can manage very 
formidable adhesions, but, when an operator of limited ability en- 
counters adhesions that he can not handle safely, he will be more 
sure of success if he relies upon draining the cyst or that part of it 
which can not easily be removed. Recovery is sometimes tedious, 
but generally sure, according to my observations. 

The following cases of suppurating ovarian cysts, reported by 
Dr. Keith, together with his comments on them, are of such great 
value tbat I quote them in full : 



SUPPURATINa OVARIAN CYSTS. 

The following narratives help to show that operation ought to 
be the rule of practice in cases of acute suppurating cysts, or when 
typhoid symptoms come on after tapping : 

Ten years ago, when cases of ovariotomy were few, and there 
was little to guide one in unusual circumstances, a young woman in 
the last stage of ovarian disease came to me a long journey from the 
north. The fatigue of traveling was too much for the strength that 
was left, and she arrived completely worn out. It did not seem 
possible that, in such a condition, life could be prolonged many days, 
for the pulse was almost imperceptible, there was vomiting and diar- 
rhoea, oedematous limbs, and albuminous urine, while a profuse fetid 
discharge was going on from an opening near the umbilicus. The 
intensity of this putridity was such that one became aware of it 
before entering the house, and the antiseptics of those days were 
powerless to arrest it. Day after day I went expecting and hoping 
to find her dead, yet, though shriveled up like a mummy, with an 
aspect scarcely human, respiration went on for nearly a mouth, the 
brain retaining its clearness, acutely alive to what was going on 
around. To remove a putrid cyst in such a condition of feebleness 
did not at that time even occur to me ; yet, since then, I have oper- 
ated more than once under circumstances not less unfavorable, and, 
looking back upon this case now, I think that operation might have 
turned out well ; certainly death after it would have been the more 
merciful way. 

Soon again (December, 1864) there came another case of very 
large tumor. The patient had been jolted for some hours in a coach, 



544 DISEASES OF WOMEN. 

and, in the hope of relieving the pain thus set up, tapping was per- 
formed after her arrival. The pain was not relieved, abdominal 
distention from flatus became excessive, and typhoid sj-mptoms rap- 
idly set it. Fearing a repetition of the slow-death process — which 
those wlio saw will not easily forget — ovariotomy was this time per- 
formed during the semi-delirium of septic fever. This was proba- 
bly the flrst time that surgery broke in upon an acutely inflamed 
peritonaeum. The intense lividity, amounting almost to blackness, 
of the abdominal contents, and the spongy tenderness of inflamed 
intestine, were then strange to me, though thought little of now. 
Recent lymph was present everywhere, adherent bowel and mesen- 
tery hedged in a thick-walled cyst, the base of which was in a com- 
plete state of slough. Inflammation had gone on to gangrene, and 
there was intense putridity, just as in the previous case. After an 
operation which went on for two hours, the j)atient was placed in 
bed, cold, vomiting, and nearly pulseless. It seemed as if we had 
simply killed her, yet she got rapidly into heat, the restless delirium 
at once disappeared, there w^ere warm perspirations, much sleep, and 
a recovery without a drawback. 

This case, which was at the time fully reported in the " Lancet,"' 
1865, page 480, has been to me as a landmark. Since then I have 
ten times met with cases of acute suppurating cyst, besides two 
chronic cases. In all of these, save one, the chance of ovariotomy 
was given, however hopeless looking the case might be. In the 
exceptional case ovariotomy would also have been performed had it 
been possible to remove the patient from her poor home and un- 
favorable surroundings. She was seen with Dr. Menzies on the 
third day after her fourth confinement. He had been called to her 
for the first time only the day before. A large ovarian cyst had 
existed with at least two of her pregnancies. The distention was 
so enormous that urgent dyspnoea had to be relieved at once by tap- 
ping. Upward of six gallons of fluid, containing much blood and 
j)us^ were got away, and ovariotomy was agreed on as soon as she 
could bear removal. This could not be accomplished, and, after 
three weeks^ tapping was again had recourse to. This time the pus 
was intensely putrid, and, as the cannula got choked with pieces of 
fetid lymph, an incision, sufficient to admit two fingers, w^as made 
into the cyst, and its putrid contents thoroughly cleared out. For- 
tunately, the cyst was single ; a perfect recovery took place, and this 
p&tlent has had two children since. JS^one but the strongest of 
women could have borne the exhausting suppuration that went on 
for nearly four months. Pulse and temperature remained high, and 



ILLUSTRATIVE OASES OF OVARIAN NEOPLASMS. 545 

of at least six weeks of her illness she has now almost no remem- 
brance. Recovery in such circumstances must be rare ; yet it may 
be well to note that during the whole time she was supported en- 
tirely on milk and buttermilk, and had no stimulants whatever; 
neither was there any washing out of the cyst. 

Of the ten more or less acute cases operated on, eight recovered, 
while the two chronic cases got well easily. During 1872-"r3 sev- 
eral came about the same time, and the following series of seven 
occurred in the course of my second hundred operations for ovarian 
tumor, none of which have yet been published. To an onlooker, 
few operations look so hopeless as those for the removal of acute 
suppurating cysts. The general condition is always unfavorable, 
and, as a rule, ovariotomy is in these circumstances tedious and se- 
vere. To be beheved in, such cases need almost to be seen. 

Suppurating Ovarian Cyst; Ovariotomy; Eecovery. — Mrs. M., 
aged thirty-five, was sent to me in the end of June, 1871, by Dr. 
Soutar, of Golspie. An ovarian tumor was detected toward the end 
of 1869. In January, 1870, she had severe abdominal pain. After 
a fortnight's rest, this passed off, but only to return with increased 
severity. Loss of flesh and rapid growth of the tumor followed, 
and it was nearly a whole year ere she was again able to be out of 
bed. During this time her sufferings, as told by a friend, must 
have been great. Often for weeks together she could not be moved 
from one position, while the changing of her dress, or the arranging 
even of the bedclotlies, brought on such pain that her cries were 
heard in the street. It was eighteen months after her first illness 
that she was able to make the journey to town. I saw her after she 
had rested two days. The pulse was then 156 ; the temperature 
103°. 

She was a tall, fair-complexioned, blanched-looking woman, ex- 
tremely emaciated ; the lips and fauces were very angemic ; the girth 
at the umbilicus was forty-six inches ; the lower part of the tumor 
felt solid, but fluctuation was distinct above the umbilicus; the ab- 
dominal wall was hard, thickened, and oedematous ; the skin even 
in some places feeling as if adherent. It was evident that there 
were adhesions of a very unusual nature. 

Two days after this examination, with the assistance of Dr. Drum- 
mond, of Nice, I removed three gallons of thick pus by tapping some 
inches above the umbilicus. A large, prominent, hard tumor re- 
mained below this. Much relief followed, and for a few days the 
pulse and temperature somewhat fell. In three weeks the cyst had 
refilled ; the pulse was again rapid and feeble, varying from 120 to 



546 DISEASES OF WOMEN". 

160 ; the morning temperature was 101° to 102° ; that of the even- 
ing, 103° to 101°, sometimes higher. The skin was dry and shriv- 
eled, and she was, if possible, thinner than before. 

Ovariotomy was performed on the 13th of July, 1871. Sul- 
phuric ether was given. The incision extended from the umbilicus 
downward eight inches. The wall was much thickened, the peri- 
tonaeum of almost cartilaginous hardness, and the whole parts so un- 
usually vascular, that no time had to be lost in completing the oper- 
ation. The upper cyst was emptied of its purulent contents, the 
lower semi-solid portion thoroughly broken down, and the cyst- 
walls, weighing eighteen pounds, dragged out. There was not any 
part of the tumor non-adherent. The connections were of the ut- 
most firmness, especially those in the pelvis. Posteriorly, there was 
more adherent intestine and mesentery than I have met with except 
twice. The peritonseum was thickened by old lymph. Large flakes, 
like pieces of cartilage, were peeled off the wall after removal of the 
tumor. Some of these were as large as the hand, and it was difficult 
to tell what really was the peritonaeum. All bleeding points were 
tied with Lister's ligatures, a broad, thick pedicle secured by a clamp, 
and the wound closed wdth silk sutures. 

The operation lasted upward of an hour ; much blood had been 
lost, and she was placed in bed with great fears for her immediate 
safety. She lay for some hours with an almost imperceptible pulse. 
She was restless, and great bursts of clammy perspiration broke out 
every now and then, such as one sees in those suffering from the 
shock of injury. Fortunately, there was no vomiting. By evening 
she was comfortably warm ; flatulence was troublesome ; there was 
much thirst. Pulse, 125 ; respirations, 32 ; temperature, 102.° 

She slept during the night, but got low and faint toward morn- 
ing, and there was some vomiting. Brandy and soup enemata were 
given every two or three hours. She improved toward evening. 
Flatus first passed forty-four hours after operation. The pulse w^as 
rapid and feeble, and she scarcely opened her lips for many days. 
In the third week there was pain and swelling in the right iliac 
fossa, and fluid formed. Four weeks after operation this swelling 
was punctured, and about a teacupf ul of yellow serum was removed 
by a syringe ; the rest was absorbed. She was able to return home 
in five weeks, and is now a strong, healthy woman. 



CHAPTER XXX. 

DISEASES OF THE FALLOPIAN TUBES. 

Before considering the various morbid conditions of the Fallo- 
pian tubes, I shall briefly review their anatomy. 

The tubes — one on either side — are contained in the broad liga- 
ments, and run transversely from each lateral corner of the nterus 
out to the ovaries, to which they are joined by a short, ligamentous 
cord. Each tube, or salpinx, is four to five inches long ; the right 
tube is usually slightly longer than the left. The diameter in- 
creases from the uterus toward the ovary ; and the canal similarly 
increases. They are formed of an external peritoneal covering, of 
an internal mucous surface, and of an intermediate proper muscular 
tissue, arranged in two layers, of which (1) the longitudinal seems 
to be a prolongation from the uterus ; while (2) the circular, pecul- 
iar to the tubes alone, ends as a kind of sphincter upon the abdomi- 
nal orifice. 

The mucous membrane is lined by cylindrical epithelium, the 
motion of whose cilia is toward the uterus. Numerous fusiforai 
cells are found in an incompletely- developed connective tissue. The 
arteries arise from the utero-ovarian trunk, entering the substance 
of the tube at its lower border. The veins empty into corresponding 
vessels. The nerves come from the hypogastric and ovarian plexuses. 

A study of the development, in the embryo, of the female or- 
gans of generation, shows the closest structural relationships existing 
between the tubes and uterus. Some observers claim that part of 
the menstrual blood comes from the tubes. 

Anomalies of form and situation are frequent ; the tubes may 
be absent ; there may be only one tube ; alternate stenosis and dila- 
tation may exist ; and there may be marked difl:erence in length be- 
tween the two tubes. 

Two abdominal orifices for a tube may exist, and fimbria? from 
each may project into the peritoneal cavity„ 



548 DISEASES OF WOMEN. 

Again, the tube may be dislocated, twisted, bent into knuckles, 
or may have suffered hernia along with portions of the intestine. 
The tubes may open into the womb abnormally low down, which 
may possibly account for placenta prsevia in some cases. 

The tube may be completely separated from the ovary. A rare 
condition is hernia of the mucosa, where the muscular tissue is ab- 
sent or so weak that it allows the mucous membrane to protrude, 
forming a pocket into which the fecundated ovum may drop. 

Neoplasms may be found in the tubes ; among them tubercle, 
carcinomata, sarcomata, cysts, fibromata, myomata, lipomata, and 
papillomata. Morgagni's hydatid is a vesicle often hanging to a 
fimbria. Cysts, tubercles, and fibromata are the most frequent of 
these neoplasms, but even these are so rare that they need only to 
be mentioned here. 

So many morbid tubal conditions are either direct or indirect 
sequelae of salpingitis or " catarrh of the tubes " that this condition 
first demands attention. 

Salpingitis. — Inflammation of the tubes may be acute or chronic. 

Pathology. — In acute catarrh the mucous membrane of the tube 
is thickened, congested, and covered wdth neutral or acid mucus, 
muco-pus, or an opaque fluid which contains lymph-corpuscles and 
epithelial cells w^hich are changed in form or which have undergone 
granular degeneration. 

The longitudinal folds of the mucosa are effaced ; the fimbriae 
are obliterated or obscured by inflammatory products, and the ends of 
the tubes are usually closed. If not, the contents of the tube enter 
either the uterus or the abdominal cavity in which latter case pelvic 
peritonitis results. In very severe cases (and sometimes in diph- 
theria) false membranes may be formed in the mucosa. 

Peri-salpingitis usually occurs in severe cases. The tube is in- 
creased in size, tortuous, and dilated irregularly, and when the puru- 
lent secretion accumulates the tube which is closed at each end be- 
comes greatly distended. This is known as pyosalpinx. In this 
condition the epithelia are flattened and the mucous and muscular 
coats are gradually thinned, so that rupture into the peritoneal cav- 
ity is not infrequent, in which case general peritonitis or pelvic 
peritonitis results. In rare cases the rectum has been perforated 
and the contents of the tube discharged through that viscus. 

Chronic catarrh is accompanied by the adhesions of the tube to 
the neighboring organs in some cases, the result of localized perito- 
nitis. The lower part of the tube is adherent oftener than other 
adjacent parts. The ovary is also congested or inflamed in the ma- 



DISEASES OF THE FALLOPIAN TUBES. 549 

jority of cases. The mucosa is much thickened, and secretes a fluid 
which is either thin and waterj or thick and cheesy, not purulent as 
in acute salpingitis. 

Occasionally, chronic dropsy of the tube is the result of the secre- 
tion of serous fluid, and the tube may become distended and form a 
small cystic tumor; or, it may be converted into several distinct 
cysts without any intercommunication, since the tube between them 
has been totally obliterated by the inflammatory process. 

This is known as hydrosalpinx. In this condition all the coats 
of the tube sometimes become extremely thin. Dropsy of the 
tube may suddenly terminate when an opening of the duct into the 
uterus occurs ; this, however, is very rare. 

Cases are recorded where a hydrosalpinx has communicated with 
an enlarged and diseased ovary. 

Symptoms. — This affection so often follows gonorrhoea or endome- 
tritis that the symptoms of salpingitis are merged with those of the 
primary disease or are completely masked by them, until pelvic 
peritonitis occurs. This is the most dreaded outcome of salpingitis, 
and too frequently the first symptom which leads one to suspect its 
occurrence. Usually, however, when salpingitis occurs there is an 
increase in the symptoms so marked as to attract attention. The 
pain though less pronounced than that of peritonitis, is sufficient to 
compel the patient to rest in the recumbent position. There is usu- 
ally some constitutional disturbance or slight symptomatic fever. In 
acute cases this fever is well defined, and attended with deranged 
digestion and nutrition. In short, it may be stated that the local 
and constitutional symptoms are the same as in other pelvic in- 
flammations, less acute than in pelvic peritonitis or pelvic hem- 
atocele, but as well marked as in pelvic cellulitis of a mild type. 
When pyosalpinx occurs there are symptoms of mild blood poi- 
soning. 

Menstrual disturbances usually occur in salpingitis but not al- 
ways. It frequently happens that the severity of the s}Tnptoms is 
lessened, indicating that the inflammation has subsided, but it again 
lights up, and becomes for a time as marked as at first. 

Periodical watery fluxes with diminution in the size of a swell- 
ing in the region of the tubes, and accompanied by colicky pains, 
are indicative of tubal dropsy where the tube is incompletely closed 
near the uterine end. 

Physical Signs. — In the first days of the inflammation before the 
tubes are distended the chief sign is tenderness in the region of the 
tubes. When a tumor can be made out it is felt to be elongated, 



550 DISEASES OF WOAIEX. 

fluctnating, movable, not separable from the utenis. and lying on one 
side in the retro-nterine space. 

By aspirating, a fluid -which contains columnar ciliated epithehmn 
is found. Of twenty one cases in which the fluid was examined 
by my colleague Dr. F. Ferguson, this epithelium was found in 
nineteen. This is a most valuable diagnostic sign, but as aspirating 
is not without danger it should not as a rule be resorted to. 

Except when the tube is enlarged a positive diagnosis of salpin- 
gitis can not be made. 

The condition with which salpingitis is apt to be confounded is 
a small ovarian cyst. It is impossible, often, to positively decide 
this question immediately. By waiting and watching the case the 
ovarian cyst will be found to gradually become larger without any 
increase in the constitutional symj^toms ; while in tubal disease the 
increase in size is limited. 

Prognosis. — I believe that salpingitis may subside, but as a rule 
the tube is obliterated entirely or in part. When hydrosalpinx oc- 
curs there is not much chance of recovery. In pyosalpinx recov- 
ery can only be insm-ed by removal of the tube. 

Causation. — Gonorrhoea of the uterine mucosa, and simple and 
puerperal acute endometritis are its chief causes; but it may occur 
during the course of any acute infectious disease, from the presence 
of neoplasms or from intense hypertemia of the generative tract, as 
in prostitutes. 

It is possible that syphilis may cause it just as it causes otitis or 
ozsena. Sometimes it is secondary to diseases of the ovaries. 

Microbes may find entrance into the tubes, and on this (not yet 
proved) statement, Sanger, of Leipsic, classifies salpingitis as S. gon- 
orrhoica, S. tuberculosa, and S. actinomycotica. He also has a salpin- 
gitis septica including S. py^emica, ichorosa, puriilenta, and diphthe- 
ritica, which are due to specific microbes identical with those produc- 
ing tramnatic infection. 

Treatment. — Acute and subacute salpingitis, in the early stages, 
should be managed in the same way as other inflammations of the 
pehic organs and tissues. Best and anodynes for the relief of pain ; 
counter-irritation and attention to the bowels are the chief indica- 
tions. Wlien the acute symptoms subside, iodine, ichthyol, and 
mercmw have been used locally, and massage and electricity also, 
with some possible good results. 

TVhen once hydrosalpinx or pyosalpinx is developed it is doubt- 
ful if any treatment except laparo-salpingotomy is eflective. Cer- 
tainly this is the case in pyosalpinx. 



DISEASES OF THE FALLOPIAN TUBES. 551 

Laparo-salpingotomy, as first practiced by Tait and Hegar is the 
recoofnized treatment in these otherwise incurable diseases of the 
tubes, and the results are very satisfactory. It is not always possi- 
ble to ascertain whether hydrosalpinx or pyosalpinx exists ; hence it 
is wise to perform laparotomy and remove the diseased tube if the 
subject of pyosalpinx ; should a hydrosalpinx be found it may be 
deemed best to try stripping the tubes or catheterizing and cleaning 
them out and restoring them to their normal situation, and trusting 
to curing the trouble thereby. This has been tried by Polk, but 
the results are not sufficiently well known to determine the merits 
of this procedure. In the former case the woman is sterile, in the 
latter not necessarily so. 



TUBERCULOSIS OF THE TUBES. 

Pathology. — In this condition the tubes are rigid, thick, and 
bound down by pseudo-membranes. The thickening results from 
infiltration. 

Acute catarrhal salpingitis usually co-exists. Both ends of the 
tube are usually closed but between them the cavity is much dilated, 
containing mucus, muco-pus, pus, or cheesy debris. The vessels of 
the tubes are enlarged and thickened and the nodules upon them, as 
well as the nodules on the mucosa and in the muscularis contain the 
tubercle bacillus. 

Symptomatology. — The tubercular diathesis w^hich is usually 
present is the only indication of the nature of this affection. It may 
be possible to recognize the dilated tube by palpating the abdomen, 
and by manual examination when its immobility, size, tortuosity, and 
nodular feel, taken in connection with the constitutional conditions 
causes us to suspect tuberculosis of the tube. 

Possibly the dilated tube may be felt by a vaginal examination. 
German gynecologists advise that the secretions from the uterus 
should be examined for the bacilli which if found are evidence of 
tuberculosis. 

Treatment. — Were it possible to diagnosticate isolated tubercu- 
losis of the tubes, extirpation would afford a means of (possible) radi- 
cal cure. 

H^aiMATOSALPINX. 

Blood in the tubes induces hypertrophy of the walls except at 
one point, which, growing thinner and thinner, forms a sac varying 
in size from a pin's head to an orange. Any portion of the tube 



552 DISEASES OF WOMEN. 

may be the seat of such a tumor. Fatty degeneration or ulceration 
of the walls of the tube may induce rupture and peritonitis. At times 
the uterine end of the tubes permits of partial or complete evacua- 
tion of the tumor. 

Symptomatology. — The symptoms are the same as those of hydro- 
salpinx except that they are more acute at Urst, and at the time of 
the menses are all markedly increased in intensity. 

Etiology. — Intense hypersemia of the genitals, retroversion, 
typhoid fever, measles, and purpura hsemorrhagica have been kno^vn 
to cause hsematosalpinx. "When blood can not make its way out of 
the uterus it may flow back into the tubes. There is no doubt, how- 
ever, that the mucous membrane of the tubes alone is capable of 
being the source of the haemorrhage. 

Treatment. — Laparo-salpingotomy is the proper treatment, and if 
the diagnosis is made the tube should be removed before peritonitis 
occurs. The prospects of a favorable result are then very good. 

I^PARO-SALPINGOTOMY AND OVARIOTOMY. 

The operation for the removal of the tubes and ovaries differs in 
many respects from that of ovariotomy for cystomata, and requires 
a word of description : 

The incision in the abdominal wall should be short, just sufficient 
to admit two fingers. Extra care is necessary to avoid wounding 
the omentum or bowels. If the intestines are adherent to the ab- 
dominal wall, the incision should be enlarged in order to find a 
part where there are no adhesions, before opening the peritongeum. 
This is easier than to separate the intestines. This complication is, 
fortunately, seldom met. I have often found the omentum adherent 
to the intestines, and occasionally to the abdominal wall near the 
median line, but it is generally free on one or both sides, so that the 
tubes and ovaries can be reached by passing the fingers beyond the 
adhesions and pushing the omentum to one side. When no free 
part can be found, the omentum should be picked up and divided 
in the incision, and the bleeding vessels tied. Two fingers should 
be passed into the wound and the fundus uteri found. This is a 
guide to the tubes. Adhesions, which are usually present, should 
be separated gently ; and when both tube and ovary can be found, 
they should be hooked up with the fingers and brought out through 
the wound, or into it. By traction in this way a pedicle is found 
and included between the fingers, when it can be transfixed and 
tied. The Staffordshire knot is the best to use. 

Much skill, which can only be obtained by practice, is required 



DISEASES OF THE FALLOPIAN TUBES. 553 

to separate the adhesions and bring out the tubes and ovaries. If 
the adhesions are old and can not be broken up easily, it is safer to 
enlarge the wound and tie and divide them. 

If the tubes are largely distended and their walls thin, the adhe- 
sions should be separated only where that can be easily done and 
the tubes emptied, or partially so, with the aspirator, and then seized 
with the forceps and brought out and the adhesions separated. The 
pedicle is then ligated, and tube and ovary removed. Where there 
are many adhesions there will be some bleeding, which usually can 
be stopped by pressure, but it is safe to drain for a day or so. 

The after-treatment is the same as after ovariotomy in general. 

ILLUSTRATIVE CASES. 

Hydrosalpinx ; Repeated Discharge of the Contents of the Tube 
through the Uterus; Recovery. — My friend Dr. William H. B. 
Pratt, called me to see a rather delicate and very refined lady, who 
gave a history of some rather obscure pelvic affection, which had ex- 
isted for more than a year. The doctor found, when he was first 
called to see her, that she had a retroversion of the uterus, and pre- 
sumed that this was the whole cause of her suffering. He was able 
to restore the uterus to its place, but could not keep it in place, be- 
cause a pessary or cotton tampon caused great suffering. This was 
the history at the time that I saw her. I also learned that she was 
unable to ride or walk for any length of time, owing to the severe 
pelvic and rectal tenesmus, which the erect position brought on. 
By a digital examination, I found the retroversion of the uterus, and 
also a cystic tumor, low down on one side of the sac of Douglas. 
The tumor was oblong and elastic, and there was distinct fluctua- 
tion. I suspected that it was an ovarian cyst. 

Treatment gave her some relief, but she did not recover. She 
had repeated attacks of pain in the pelvis, and suffered so much on 
taking exercise that she was obliged to live an invalid life. 

Some time after seeing her the first time, she menstruated more 
freely than normal, had more pain and discomfort than usual. Soon 
after the menses she had a sudden and free discharge of fluid of a 
whitish, turbid character, and was much reUeved after it. I exam- 
ined her soon thereafter, and found that the cystic tumor had en- 
tirely disappeared. Her symptoms, though modified for a time, 
returned again, and again the tumor was found in the same place. 
Another discharge of fluid occurred, followed by relief and the dis- 
appearance of the tissues. 

This much of the history, in the way of filling and emptying of 



554 DISEASES OF AY0ME:N". 

the tube, was repeated a number of times with this difference — that 
the accumulation of fluid was less. 

I regret that 1 do not have notes of the length of time that the 
trouble lasted, but it will suffice to say that the patient recovered 
completely, and has had no return of her hydrosalpinx of seven 
years ago. 

Double Pyosalpinx; Recovery without Operative Interference. — 
The notes of this case were given to me by Dr. Buckmaster. The 
history is a rare one, and is of special interest. I have in the past 
doubted if ever pyosalpinx ended in recovery without removal of 
the tubes, but this case shows that such may occur. The patient 
was married, and twenty-five years old. She had an abortion pro- 
duced, and peritonitis and salpiDgitis followed this maltreatment. 
Dr. Buckmaster saw her two weeks after the time of the abortion. 
She was then suffering from severe pelvic inflammation. The tem- 
perature was at that time 104° F. There was marked pain, tender- 
ness, and abdominal distention. The products of the inflammation 
quite filled the pelvis, and there was fixation of the uterus. She 
was treated in the usual way by the doctor, and, at the end of two 
months from the time that she first came under his care, " the in- 
flammatory products had largely disappeared, and the uterus was 
slightly movable, but on each side there were two masses about the 
size of small lemons. Several days afterward there was a sudden 
discharge of ill-smelling pus. On examination at this time it was 
found that the mass on the left side had disappeared. Soon after 
this there was another free discharge of pus, and the mass on the 
right also disappeared. For three months subsequently there was a 
slight but constant discharge of pus from the cervix uteri, but finally 
it ceased. One year from the attack the patient was in fair health, 
but suffered from pelvic pain at times, which appeared to be due to 
adhesions of the peritonitis. 

The histories of many cases of pyosalpinx might be given in 
which no benefit could be obtained by general treatment, but were 
promptly relieved by salpingotomy. In fact, the only reliable treat- 
ment for the relief of this affection of the tubes is to remove them. 
The operation is the same as for the removal of the ovaries, and 
need not be described here. Those who desire full details of this 
subject are referred to the works of Lawson Tait, whose brilliant 
achievements in this department of surgery were the first and greatest. 

ISTo case of hsematosalpinx has come under my observation, hence 
the reader is again referred to Lawson Tait for cases illustrating this 
subject. 



CHAPTEK XXXI. 



PELVIC CELLULITIS. 



The anatomical distribution of tlie pelvic cellular tissue is the 
same as that in all other parts of the body, and its function in this 
region is also the same as elsewhere. It tills in all the interspaces 
between organs and tissues, being most abundant where there is the 
greatest mobility, and it is the principal accommodating and protect- 
ing medium through which the blood-vessels and nerves are con- 
veyed to all parts of the body. 

In the pelvis it fills all the unoccupied spaces lying between the 




Fig. 205. 
37 



y 31. levator aui', 

-Diagrammatic transverse section of the pelvis (Lusehka). 



556 DISEASES OF WOMEN. 

pelvic organs, except between tlie peritonaeum and the middle por- 
tion of the fundus uteri. At that point it exists (if at all) in so 
small a quantity that it can not be demonstrated. Inflammation of 
the cellular tissue here located has received many names — pelvic 
cellulitis, peri-uterine cellulitis, parametritis, peri-uterine phlegmon, 
pelvic abscess, and inflammation of the broad ligaments. 

I prefer the term pelvic cellulitis, which was given to it by Sir 
James Y. Simpson because it indicates the nature and location of 
the disease. Inflammation of the cellular tissue may occur wherever 
that form of tissue is found, hence the term pelvic cellulitis does not 
deflnitely locate the site of the disease, and yet the name is as spe- 
cifically descriptive as any of the other terms used. Moreover, pel- 
vic cellulitis, limited to the areolar tissue around the cervix uteri, 
and between the folds of the broad ligaments, comes under the ob- 
servation of the gynecologist more frequently than in any other 
location in the pelvis ; hence it should be understood that the term 
pelvic cellulitis is here applied to inflammation of the cellular tissue, 
located in the broad ligaments and about the supravaginal portion 
of the cervix uteri. 

Pathology. — This differs in no respect from inflammation of 
cellular tissue elsewhere, except so far as it may be modified by the 
peculiarities of the location. There is, first, a stage of active con- 
gestion, followed by an effusion of blood serum, and later, an exuda- 
tion of the higher organized constituents of the blood, and, finally, 
suppuration. 

In some cases the inflammatory process stops short of suppura- 
tion, and the products of the inflammation are removed by absorp- 
tion, and the recovery is soon completed. This is called ending in 
resolution. There are a few cases in which the products of the mor- 
bid process are packed so densely into the tissues that the circula- 
tion is arrested and the cellular tissue destroyed, and a dead mass or 
slough is formed. 

These cases, fortunately rare, are very severe, and sometimes fatal. 
They are also complicated with inflammation of other organs in the 
pelvis, as a rule. In fact, fatal cases are generally complicated, the 
uncomplicated cases rarely proving fatal. 

When suppuration takes p ace, the pus usually makes its escape 
by some one of the following avenues, mentioned in the order of 
frequency as nearly as can be : Yagina, rectum, bladder, abdominal 
walls, saphenous opening, pelvic floor near the anus, pelvic foramina, 
obtm*ator or sacro-ischiatic foramen, and through the pelvic roof into 
the peritoneal cavity. 



PELVIC CELLULITIS. 



557 



I have seen three cases in which the pus from an abscess in the 
broad ligament burrowed outward to the iliac fossa, and then ex- 
tended upward to the diaphragm, and in one it opened through the 
lung into the ?arge bronchial tube. Brief histories of these cases 
will be given at the end of this chapter. 

"When the pus escapes into the vagina or rectum at the most de- 
pendent part of the abscess sac, the evacuation is usually complete, 
and the after-drainage favorable ; the walls of the abscess come to- 
gether,, and the cavity is soon closed. The walls of the sac become 
thin by absorption, the fixation and swelling of the parts subside, 
and the recovery is complete. 

In examining a case in after years that I had treated for cellulitis, 
I found that all traces of the disease had disappeared, so far as could 
be ascertained by physical exploration, and the functions of the pel- 
vic organs were all performed normally, thus showing that the recov- 
ery was complete. This is the history of the pathology of the sim- 
plest cases of pelvic cellulitis. 

When the pus escapes into any other pelvic viscera at a point 
above the most dependent part of the abscess sac, the evacuation is 
necessarily incomplete, and the drainage imperfect. Chronic sup- 
puration and discharge will occur under such circumstances, and the 
duration of the case is very indefinite. This is often the result 
when the point of escape is through the abdominal walls or the pel- 
vic foramina ; but the same thing occurs sometimes when the open- 
ing is into the vagina or rectum or bladder, especially the rectum. 

Judging from several cases that I have seen, in which the open- 
ing was into the rectum, I am inclined to believe that the direction 





206. — Pelvic aDscess opening 
obliquely downward. 



Fig. 207. — Pelvic abscess opeuim 
obliquely upward. 



of the opening has something to do with keeping up the suppuration. 
When the opening is low down, and enters the rectum obliquely 
downward, and the drainage is complete, the opening will close 



558 DISEASES OF WOMEN. 

promptly (Fig. 206) ; but, if tlie opening into tlie rectum is direct or 
obliquely upward, the contents of the bowels will escape into the 
abscess sac, and keep up suppuration for an indefinite length of time 
(Fig. 207). 

These conditions in the pathology of cellulitis afford a reasonable 
explanation, perhaps the true one, of the difference in progress be- 
tween cases that, up to the time of evacuation of pus, appeared to be 
alike. 

There is yet another condition in the morbid products of the 
disease which retards recovery. In place of the suppurative pro- 
cess, invoMng the whole mass of iniiammatory products, a number 
of small abscesses are found producing a honey-comb state of the 
parts, a number of small abscesses opening into each other by small 
sinuses, and all opening into some of the pelvic viscera, by one or 
more openings. This pathological condition delays the progress of 
the case greatly. All these exceptional peculiarities in the pathology 
which complicate the progress of the disease also tend to make the 
after-effects — i. e., the damage to the pelvic organs — greater. The 
walls of the abscess are thicker, and the scar left in the tissue contracts 
more, and hence, displacements are often found. Pelvic pains of a 
neuralgic character often follow, and the functions of the pelvic organs, 
uterus, rectum, and bladder are to some extent occasionally deranged. 

There is still another form of behavior noticed in some cases. 
Suppuration takes place at one point, usually a small one, and instead 
of the pus escaping in the usual manner, it finds its way into the 
circulation causing septicaemia, which is intermittent in character. 
The temperature and pulse run up high for a time and then sub- 
side, the fever being sometimes preceded by a chill or rigor. These 
paroxysms are repeated over and over again, the general nutrition 
of the patient being greatly impaired. 

The chief cause of pelvic cellulitis is septicaemia, and is usually 
traumatic in its origin. Injuries to the uterus and vagina during 
parturition or abortion develop septic material which is conveyed to 
the cellular tissue by absorption through the lymphatics principally. 

It is possible that lymphangitis is primarily developed, and sub- 
sequently, cellulitis. Be this as it may, the fact is that two thirds of 
all the cases occur after abortion or parturition. Whenever cellulitis 
follows parturition, it may be presumed that it is caused by the absorp- 
tion of septic material from the parturient canal. It is possible, how- 
ever, that contusions of the cellular tissue occurring during parturi- 
tion may give rise to decomposition of the injured tissue and septic 
cellulitis, which, in that case, is autogenetic, and not due to absorption. 



PELYIO CELLULITIS. 559 

The other and far less common causes of cellulitis are surgical 
operations, the use of caustics, ill-fitting pessaries, dilatation of cervix 
uteri with sponge tents and direct blows, but with all of these the 
cause is septic, the morbid material being developed by the injury. 

Cellulitis occasionally occurs secondarily to some pre-existing in- 
flammation, such as endometritis, pelvic peritonitis, salpingitis, and 
ovaritis. These last-named affections, when they precede the cellu- 
litis, stand in a causative relation to it. It quite frequently hap- 
pens, however, that the above-named diseases are developed in the 
course of a cellulitis, and are caused by it, and hence become com- 
plications of the cellulitis. 

The duration of cellulitis varies very much according to the ex- 
tent of the inflammation, but more especially is the progress modi- 
fled by the termination of the inflammatory process. In case that 
resolution takes place, recovery may occur in a few weeks, but on 
the other hand, if suppuration occurs and the discharge of pus is 
incomplete, owing to the unfavorable point of escape, then chronic 
suppuration may go on for months or years. 

When suppuration takes place and the discharge of pus is at the 
dependent part of the abscess, the average duration of the disease 
is about six weeks. Much has been said about chronic cellulitis, but 
I have never been able to recognize any such condition. Chronic 
suppuration in a badly-drained abscess may go on for any length of 
time — this we often see ; also, frequent or repeated attacks of cellu- 
litis may occur, but a chronic or continuous inflammation such as 
we see in inflammation of mucous membranes, is something which I 
have never met with in practice. This is quite in accord with what 
we know of cellulitis elsewhere, where the process begins, pro- 
gresses, and ends and recovery follows, or, it may be, that the inflam- 
mation progresses to the stage of suppuration, and for some reason 
suppuration is kept up, but this is simply a chronic condition of one 
stage of the process. 

1 think that the so-called chronic cellulitis, recognized and treated 
as such by some authorities, is nothing more than the products of 
the inflammation which remain after the inflammation itself has 
subsided. 

The consequences of pelvic cellulitis depend largely upon the 
extent of the tissue involved and the quantity of inflammatory exu- 
date. Sometimes, the tissues become infiltrated with the products 
of the inflammation which do not all break down in the suppurative 
process ; when this occurs, it requires a long time to effect the absorjv 
tion of these products, and during that time, the patient is likely to 



560 DISEASES OF WOMEN. 

suffer from derangement of the functions of the pelvic organs and 
also from pelvic pain. So, also, when the products of the inflamma- 
tion have all been disposed of, if much damage has been done to the 
tissues, which is usuallj the case, contractions follow which are apt 
to displace the pelvic organs to some extent, and to give rise to 
trouble ; and yet, in the majority of uncomplicated cases of cellu- 
litis, complete and perfect recovery generally takes place. This, I 
have frequently been able to verify by subsequent examination of 
cases that I have formerly treated. More than that, it not infre- 
quently happens that patients, after a well-delined cellulitis, recover 
and bear children, showing conclusively that the recovery was com- 
plete and perfect. 

In the clinical history of pelvic cellulitis, as manifested by the 
symptoms and physical signs presented, there is a great variation in 
different cases ; just as the extent of the local lesions differ in degree 
and extent, so the symptoms vary in their severity. There is usu- 
ally a decided symptomatic fever as indicated by the frequency of 
pulse and elevation of temperature. This may, or may not be pre- 
ceded by a chill or rigor which is promptly followed by fever. 

The temperature as a rule is not high, from 101J^° F. to 103° F. 
being about the range. There is also marked derangement of the 
digestive organs ; sometimes, there is some nausea and vomiting, 
almost always tympanitic distention of the bowels, and usually con- 
stipation. It is rare that there is any delirium or very marked de- 
pression of the nervous system. The patient usually complains of 
pain, the intensity of which varies considerably ; it is usually most 
marked in the rare cases which arise from causes other than parturi- 
tion at the full term. 

When the cellulitis follows delivery, there is abundant room for 
the products of the inflammation in the cellular tissues of the largely 
developed broad ligaments, and so the pain which is usually caused 
by pressure of these products, is not so great. In other cases due to 
injuries, intercellular haemorrhages, and the like, the tissues resist 
the distention and the exudation, and hence the pain is much greater, 
and there is usually decided disturbance of the function of the pel- 
vic organs. 

If the attack comes on when the menstrual period is near there 
may be a monorrhagia. There is also quite often vesical and rectal 
tenesmus. There is tenderness on deep pressure in the iliac regions, 
and the pain is usually aggravated by any movement on the part of 
the patient. This usually compels the sufferer to rest quietly on the 
back. Occasionally, some relief is obtained by drawing up the 



PELVIC CELLULITIS. 561 

limbs while resting on the back, bnt this position is not by any means 
as frequently assumed and persistently maintained as in peritonitis. 
These symptoms, both general and local, usually continue without 
much modification, except that relief which may be obtained 
through the influence of medication, until the exudation is com- 
pleted; then there is usually a lowering of the temperature and 
pulse, and relief from pain. The temperature, however, usually re- 
mains above 100° F. 

When suppuration begins, there is a renewal of the symptomatic 
fever ; sometimes a chill precedes this recurrence of fever. On the 
other hand, if resolution takes place, the fever does not return to 
any very great extent. During the suppurative process until the 
time when the pus is discharged, the temperature remains usually 
above 100° F., sometimes, suddenly running up to 103° F., indicat- 
ing that there may be a little acute septicemia. When the abscess 
opens and is completely emptied, there is usually a prompt and al- 
most complete relief from the symptomatic fever. 

In case that the pus remains imprisoned or is only partially evac- 
uated, and the suppuration and discharge continue to go on, there is 
usually marked constitutional disturbance, manifested by high tem- 
perature which varies abruptly in degree ; at times running down 
almost to normal and again going up to 104° F., or to 104r|^° F. 

Physical Signs, — These necessarily differ according to the stage 
of progress of the inflammation. During the stage of engorgement, 
a digital examination usually detects only swelling of the parts and 
tenderness on pressure, and if the examiner's sense of touch is very 
acute, increased heat may be detected ; any effort to move the 
pelvic organs will usually cause pain. When the exudation takes 
place, the touch detects marked induration of the parts involved, 
and when it is complete, a well-defined tumor in both broad liga- 
ments will be found, or it may be that this mass is found on either 
side of the cervix. If the tenderness w^hen pressure is made upon 
the abdominal walls is not great, and there is not much tympanitic 
distention, the tumor can sometimes be accurately outlined by the 
bimanual examination. Usually, however, not much can be accom- 
plished in this way because of the distention of the abdominal 
walls and the tenderness on pressure there. 

The size of the tumor of course depends upon the extent of the 
exudation ; in some cases it is not larger than a small orange, in oth- 
ers, both broad ligaments may be split up, and so filled with the 
exudate as to extend above the true pelvis and come in contact with 
the abdominal walls, so that the mass can be easily identified by ab- 



562 DISEASES OF WOMEN". 

dominal palpation. This I have seen in but one case, though I have 
frequently seen the tumor on one side large enough to be distin- 
guished in this way. 

The extension of the tumor upward out of the true pelvis, is 
much more frequently seen in cellulitis following labor, and it is a 
physical sign characteristic of cellulitis as compared with pelvic peri- 
tonitis. 

When the tumor occurs on one side, there is usually displace- 
ment of the uterus, that organ being pushed in the opposite direc- 
tion. When both broad ligaments are involved, the uterus may be 
carried upward and forward. In cases occurring in the non-puer- 
peral state, the uterus is often crowded somewhat downward ; in all 
cases there is most marked induration of the parts presented to the 
digital touch, and also fixation of the uterus. When resolution ter- 
minates the case, a gradual diminution of the tumor will be observed 
from time to time. When suppuration and evacuation take place, 
there is a more prompt reduction in the size of the mass. 

The physical signs sometimes change when suppuration occurs, 
but it is exceedingly difficult to detect the presence of pus in this 
location, although it is often important to do so. It is usually im- 
possible, also, to detect fluctuation, because the abscess can not be 
touched at two points far apart. One must rely then upon the soft- 
ening of the mass as felt by the index-finger, as the sign of sujDpu- 
ration. 

This is liable to be simulated by oedema of the abscess-wall, but 
this can readily be distinguished by observing that the parts pit on 
pressure. It often happens, however, that one can not decide re- 
garding the presence of pus, and if it is of great importance to so 
determine, the aspirating-needle should be employed. 

Treatment. — During the first stage of cellulitis, treatment should 
be employed with the view of controlling the inflammatory process, 
and, if not able to aboii; the trouble, to limit or circumscribe it as 
far as possible. To accomphsh this, perfect rest should be enjoined, 
and all pain relieved or made tolerable by the use of opium. The 
opium should be given by the mouth in doses sufficient to give re- 
lief, and be repeated often enough to maintain that relief. In case 
the stomach is so irritable as to refuse the opium, then it should be 
administered hypodermically. 

There is at the present day some belief that quinine given in 
large doses often controls or modifies local and inflammatory action ; 
this appears to be so in some specific inflammations like pneumonia, 
and it possibly may have some such controlling influence in celluht- 



PELYIO CELLULITIS. 663 

is ; if the stomacli will admit of it, no harm can come from giving 
ten or fifteen grains of quinine in a day at the outset of pelvic cel- 
lulitis, and possibly much good may result. Opium, however, is 
the chief agent when there is much pain or restlessness in the first 
stage ; the opium not only relieves the pain but also keeps the bow- 
els at rest, which is quite desirable ; the bowels, however, should 
not be kept too long confined ; in fact, I make it a rule when a case 
is seen early, and the rectum is distended, to empty it by means of 
a mild enema, then the bowels should be kept quiet until the tem- 
perature and pulse come down and the pain subsides, when the bow- 
els may be again moved by enema ; this secures one evacuation be- 
tween the stage of exudation and suppuration. 

Local applications sometimes give the patient a certain amount 
of comfort, and, when such is the case, there should be employed 
warm poultices, or, better, flannels wrung out of hot water, and cov- 
ered with oil-silk. 

The exudation may be limited to some extent, it is claimed by 
some authors, by the use of counter-irritants ; this, I think, is doubt- 
ful ; therefore, if they are used at all, the milder agents, like mus- 
tard paste, may be employed. During all this time the patient 
should be nourished as well as possible. If a vigorous subject, less 
care in the way of diet is necessary ; but, if feeble, an abundance of 
nourishing food should be offered. Prof. Yirgil O. Hardon, M. D., 
of Atlanta, Georgia, has practiced aspiration with good results in 
the stage of serous infiltration. A case illustrating this mode of 
treatment will be given hereafter. 

When suppuration occurs, the majority of patients will bear at 
that time sustaining means, nourishing food, full doses of quinine, 
and, in some cases, stimulants. To sustain the patient is the chief 
object at this stage. 

If the case promises to end in resolution, that should be favored 
by counter-irritants, and the internal use of the preparations of iodine 
combined with tonics. When the abscess opens, and discharge fol- 
lows, sustaining measures are all that is necessary. 

If suppuration takes place, and the pus is not discharged, but is 
retained, and causes septicaemia, it should be removed by aspiration, 
and this operation repeated if need be. If the accumulation occurs 
again and again after aspiration, the sac should be more freely opened 
and drained through the vagina. 

When the drainage is incomplete, because of the opening being 
too high up, an opening should be made at the most dependent part, 
and the drainage-tube inserted. In case that the imprisoned pus can 



564 DISEASES OF WOMEN. 

not be reached through the vagina, and the patient's life is in danger 
from chronic snppnration or septicsemia, the practice of Lawson Tait 
may be adopted — that is, opening the abdominal walls, and draining 
the abscess with a drainage-tube in the abdominal wound. 

The operation of opening the abdominal walls, and indirectly 
draming a pelvic abscess, involves all the difficulties and dangers of 
laparotomy. It is a very different thing when the abscess sac is 
adherent to the abdominal wall. Making an opening at the adher- 
ent point, and draining the sac, is little more than opening an or- 
dinary abscess. 

These are the principal points in the treatment of cellulitis ; 
other details of the clinical history and treatment will be brought 
out in the history of cases. 

ILLUSTRATIVE CASES. 

A Case of Cellulitis uncoinplicated, ending in Suppuration. — When 
this patient was twenty-six years old she gave birth to her second 
child. The labor, for some reason unknown to me, was tedioas, and 
her physician delivered her with forceps. She progressed fairly 
well until the fourth day, when she had a chill, followed by fever, 
her temperature running up to 100° and 1021°. She also had pain 
in the pelvis and distention of the abdomen, but the lochia and milk 
secretion continued, although in diminished quantity. Her general 
condition remained about the same, except that she obtained relief 
from opium given by her physician until four days afterward. At 
that time I saw her, and found, on examination, a large mass on 
the left side, tilling the upper portion of the pelvis, pushing the 
uterus to the right, and extending above the superior strait, so that 
I could distinctly make it out through the abdominal walls. This 
mass was so closely united to the uterus that it appeared to be a part 
of that organ, but was as large as the uterus itself. There was ten- 
derness to the touch, marked induration, and yet the mass and the 
uterus were very slightly movable. Pain at this time was not great, 
and the patient only complained of a little local distress and discom- 
fort, and said that she felt weak. At the same time, her pulse and 
temperature were both above 100. 

There was also laceration of the cervix uteri, and the discharge 
was muco-purulent. At this time she had very little nourishment 
for her child, and yet there was a little. She was directed to have 
perfect rest, nourishing food, opium sufficient to keep her free 
from pain and to secure comfortable nights, with tonic doses of 
quinine. 



PELVIC CELLULITIS. 565 

The disinfecting vaginal douche which had been used was con- 
tinued ; tonic doses of quinine, with fluid extract of ergot, were or- 
dered three times a day, and turpentine stupes were directed to be 
applied to the abdomen. One week later I saw her again in consul- 
tation, and learned from her attendant that but little change had 
taken place in her condition ; the temperature was lower, her appe- 
tite had improved, there was almost no pain, and she felt stronger. 
On examination, there was little if any change in the tumor, the 
physical signs being about the same ; the local discharge still con- 
tinued, but was less purulent and offensive ; the surface temperature 
varied from time to time ; occasionally the skin was hot ; at other 
times there was free perspiration. It was impossible at this time to 
detect the presence of pus in the mass in the pelvis. Five days 
afterward I saw her again, when I learned that she had had a chill, 
followed by a rise of temperature and pulse ; she had also suffered 
from rather profuse sweating. At this time her general appearance 
was less satisfactory ; she had a somewhat dusky hue of face, the 
pulse also was not as strong, and the milk had stopped entirely. 
Just before the chill her bowels had been moved by enema, and 
both patient and physician were disposed to attribute the increase in 
her trouble to the effect of the enema, but it undoubtedly was due 
to suppuration having begun. 

On examination, the mass was felt to be softer at the most de- 
pendent part, and yet no distinct flexion could be made out. Qui- 
nine was given in somewhat larger doses, the vaginal douche was 
continued, and a little wine was added to the bill of fare. 

, A few days after this her pulse and temperature improved con- 
siderably. She had then very little pain, but a sense of heat, full- 
ness, and dull aching in the pelvis. Four days after this there was 
a copious discharge of pus from the vagina, followed by marked 
improvement in the pulse, temperature, and general condition. The 
day following a marked diminution in the size of the tumor was 
noticed ; there continued to be a discharge of pus in diminishing 
quantity for nearly a week, but during that time she improved in 
general condition very decidedly. The mass gradually diminished, 
and the uterus also progressed in involution, and her strength re- 
turned, so that she became anxious to get up. She was kept quiet, 
however, for some time, until involution was complete, and all that 
remained of the inflammation was a small, hard, but not tender mass 
on the left side of the uterus and in the broad ligament, evidently 
the collapsed or the contracted walls of the abscess. 

From this time onward the improvement was steady and uniu- 



566 DISEASES OF WOMEK 

ternipted, and she was soon able to resume her duties, with the 
exception of nursing her child. At the end of two months from 
the time of the attack, she was quite well, and no traces of her 
trouble remained except a decided thickening of the broad liga- 
ment. 

A Case of Cellulitis, ending in Resolution ; the Cause Dilatation of 
the Uterine Canal by Sponge Tent preparatory to curetting. — A lady 
twenty-eight years of age, who had been married seven years, had 
suffered for some time with menorrhagia, caused by fungosities of 
the endometrium, and, although the cervical canal was quite empty, 
it was deemed necessary to dilate the canal with a sponge tent before 
removing the fungous growths. The sponge tent was introduced 
late in the evening, and remained during the following forenoon ; 
the curette was used immediately afterward, and the abnormal 
growths completely removed. Twenty-four hours after this she 
began to have pain in the region of the left broad ligament, at the 
same time developing symptomatic fever, the temperature running 
up to 101|^° F., and the pulse being accelerated. She also had a 
httle nausea when the pain was most severe, with loss of appetite 
and some tympanitic disturbance of the bowels. On digital exam- 
ination, made three days subsequently, a somewhat ill-delined mass 
was found in the right broad ligament, which increased during the 
following forty-eight hours until it attained the size of a hen's egg. 
There was a little displacement of the uterus to the right, but very 
little. This mass was quite tender to the touch, and could not be 
moved ; neither could the utenis be moved without causing acute 
pain. Opium was given to relieve the pain, and the bowels were 
allowed to remain constipated for about four days. A vaginal douche 
of borax and warm water was used twice daily, removing a muco- 
sanguinolent discharge. The pain gradually subsided, and at the 
end of four or five days the bowels were moved ; the fever also di- 
minished, the appetite slowly returned, and about this time the mass 
began to slowly diminish in size. At the end of two weeks the pa- 
tient was permitted to leave her bed and sit in her chair, but was 
not allowed to take any active exercise until after the next menstrual 
period. During that time she was confined to her bed, fearing that 
the inflammatory process might again be lighted up. After the 
period, which lasted about five days, she was permitted to resume 
her duties gradually, but was directed to rest quietly at the next 
menstrual period, which she did. Afterward, on examination, it 
was found that the mass in the broad ligament had wholly disap- 
peared, there was no tenderness and no evidence of congestion or 



PELYIO CELLULITIS. 567 

any other trouble, and her subsequent history shows recovery to have 
been complete. 

I am quite sure that the diagnosis in this case was correct, and 
1 am also satisfied that the cellulitis was caused by the treatment. 
The case occurred at a time in my practice when I knew less about 
the management of fungosities of the uterus, hence, I used a sponge 
tent before using the curette, an entirely unnecessary procedure. I 
know now that there was dilatation enough, but I followed the 
rules laid down in the books, and so employed the tent to the 
disadvantage of the patient. I am satisfied also that this case was 
due to sepsis, for at that time less was known about antiseptic sur- 
gery, and I have no reason to suppose that the sponge tent and the 
instruments used were surgically clean. This, I believe, from the 
fact that, although I have often used the curette since then and oc- 
casionally sponge tents, I have never caused cellulitis. Uncompli- 
cated cellulitis rarely proves fatal ; it is only when peritonitis super- 
venes that there is much danger in the early stages of the disease. 
The cases that end fatally do so usually in one of three ways : First, 
by acute septiceemia, which may take place immediately after sup- 
puration occurs ; second, by chronic septicaemia and exudation from 
prolonged suppuration in badly-drained cases ; third, and very 
rarely, when the abscess opens into the peritoneal cavity, and at once 
sets up a septic and usually fatal peritonitis. 

Pelvic Cellulitis following a Hsemorrhage into the Cellular Tissue. — 
A young, recently married lady, while very much fatigued from un- 
usual physical exertion, was suddenly seized with acute pain in the 
pelvic region. When called to see her, I found her lying in bed 
suffering from severe pain and some rectal tenesmus ; the pulse was 
somewhat accelerated, but the tenjperature was normal ; the skin 
moist and cool. There was no constitutional disturbance beyond 
nervous excitation due to pain. 

On examination, I found a tender point low down and to the 
right of the uterus, there was also a swelling which extended to the 
right and downward a little way, apparently between the rectum and 
vagina. The pain was relieved by opium, and on the following day 
the swelling was found to have increased and become denser, and 
yet, there was no symptomatic fever. 

Two days later the physical signs remained the same, and there 
was also a marked discoloration or ecchymosis of the vagina, especially 
in the upper and posterior part of its walls. This discoloration, taken 
in connection with the history of the case, satisfied me that the case 
was one of hasmorrhage into the cellular tissues of the pelvis. 



568 DISEASES OF WOMEN". 

The pain gradually became less bnt there was still a feeling of 
fullness and pressure in the pelvis and an annoying rectal tenesmus, 
which made the patient feel as if great relief would be obtained if 
the bowels were moved. A mild laxative was given, followed by an 
enema, which secured a free evacuation of the bowels, but in place 
of relieving, this rather aggravated her sufferings. On the sixth 
day after the attack, the patient felt a little chilly, and soon after- 
ward developed fever ; there was also a slight recurrence of the acute 
pain in the pelvis. At this time the temperature was 102^° F., and 
the pulse about 110. 

On the day following this, an examination was made, and the 
mass in the pelvis appeared to be softer than it was before ; but this 
I think was due to oedema of the vaginal walls. The fever con- 
tinued for several days and then gradually subsided, and the tem- 
perature remained about 100°. 

The pain and general pelvic tenesmus continued, though not in 
a marked degree ; her condition remained about the same during the 
following week, then the pain became more severe, the temperature 
rose a degree or more, and she was more restless and uncomfortable. 
Two days after this a discharge of pus from the vagina occurred, quite 
profuse at first, and contmued in a modified way for a couple of days. 

The discharge contained black specks which were found to be 
shreds of clotted blood. Forty-eight hours after the discharge first 
appeared, a careful examination by the touch was made in the hope 
of discovering the opening of the abscess, but without success ; a 
very careful speculum examination was then made, and by the aid 
of the probe the opening was found to the right and a little below 
the cervix uteri. The opening appeared to be just above the mass, 
which extended down, apparently, between the vagina and the rec- 
tum. A uterine dilator of small size was passed through the open- 
ing into the abscess sac and slow dilatation made. When the opening 
was sufficiently enlarged to admit a curette, a large piece of blood- 
clot was removed ; several strands of thick, prepared silk were intro- 
duced into the opening to keep up the drainage, and during the next 
few days considerable pus was discharged, together with shreds of 
old blood-clots. 

As the opening showed no disposition to close, the drainage was 
abandoned, and from this time onward the discharge diminished and 
the swelling and thickening of the tissues also slowly disappeared. 
Finally, the discharge stopped altogether, and thickening and indura- 
tion of the tissues gradually disappeared, and complete recovery took 
place. 



PELVIC CELLULITIS. 569 

Pelvic Cellulitis caused by Amputation of the Cervix Uteri. — This 
patient came into the hospital about eighteen years ago with a very 
much enlarged and eroded cervix uteri ; in fact, the cervix seemed 
to be divided into two large, round masses, the surfaces of which 
were very irregular and so vascular that they bled profusely on 
touch. This was before Dr. Emmet had told us about laceration of 
the cervix uteri and its consequences, and I supposed that the case 
was one of incipient malignant disease. This diagnosis was con- 
curred in by several of my colleagues, and amputation of the cer- 
vix was deemed the best mode of treatment, and the operation was 
performed after the method commended by J. Marion Sims. 

In removing the posterior half of the cervix, I am satisfied that 
I went beyond the walls of the uterus into the cellular tissue ; sut- 
ures were introduced to bring the flaps together and to hold them 
there, and the operation appeared to be quite a success. At the 
end of the second day the patient developed all the constitutional 
symptoms of local inflammation and soon afterward the physical 
signs of pelvic cellulitis were manifested. 

The subsequent history of the case was that of ordinary pelvic 
cellulitis which ended in suppuration and discharge, which occurred 
at a point corresponding to the right angle of the junction of the 
flaps made in the amputation. The discharge soon ceased and all 
constitutional and local disturbance subsided, and the patient recov- 
ered from the acute attack. 

She subsequently did rather badly, there was considerable con- 
traction of the scar left by the amputation, and there was evidently 
some contraction of the parts involved in the cellulitis so that she 
suffered a good deal in after years with pelvic pain and dysmenor- 
rhoea, and it became necessary to dilate the remaining portion of the 
cervical canal in order to give relief. This case is mentioned simply 
to illustrate cellulitis as it occurs after operations about the cervix 
uteri, and it no doubt was septic in its origin. The case was treated 
before the days of antiseptic surgery, and I have no doubt that I 
exposed my patient to all the septic influences possible in such an 
operation. Indeed, the management of the whole case was rather 
bad as it appears to me now, and I am inclined to believe that it was 
not at all malignant to begin with, and that amputation of the cervix 
was therefore uncalled for. Such a case now would be considered 
as a laceration of the cervix with areolar hyperplasia, and would be 
treated in the usual way. 

A Case of Pelvic Cellulitis ; the Abscess opening into the Rectum and 
Long-continued Suppuration occurring in consequence. — This patient 



570 DISEASES OF WOME^N". 

was also seen in hospital ; she gave a history of having had pelvic 
cellulitis seven months before admission. About live weeks from 
the time that she was taken ill she had discharges of pus from the 
rectum which were followed by marked relief. After this she con- 
tinued to have repeated discharges of pus in the same way ; for a few 
days at a time she would be comparatively comfortable, though never 
well ; then she would have a little fever, with considerable pain, 
and then a discharge of pus, which would give relief for a few days. 
These remittent attacks of pain and fever followed by a discharge 
of pus, continued at varying intervals up to the time that I saw her. 
On digital examination, I found fixation of the uterus, with evidence 
of induration in both broad ligaments and around the cervix, above 
the vagina. 

She was anaemic, emaciated, and had a somewhat cachectic ap- 
pearance. She was placed under ether, and a most careful examina- 
tion of the rectum made. The opening from the rectum into the 
cellular tissue was found about three inches up the rectal wall, by 
bending the probe into the shape of a hook. I was able to pass it 
from above downward and forward, showing that the opening ran 
from the rectum obliquely downward into the abscess about an inch. 
A counter-opening was made in the most dependent part of the sac 
through the vaginal wall ; the opening was made with the thermo- 
cautery. This 1 believe to be the best method of making counter- 
openings in these old cases, as haemorrhage can be avoided and the 
lymphatics closed by the cautery, which to some extent guards against 
septicaemia. 

The opening in the vagina was maintained by small drainage- 
tubes which completely drained the abscess. The patient improved 
generally and locally, and after a time the drainage-tube was given 
up ; a little discharge continued from the oj^ening for several days, 
when it closed. The case did well, and was soon dismissed from the 
hospital, although there still remained considerable induration and 
thickening of the tissues of the broad ligaments. Presuming that 
her recovery would be eifected in time, she was dismissed from the 
hospital ; but returned in about three months with a rectal abscess, 
which, when it was opened, proved to be a rectal fistula. Evidently, 
the opening in the vagina had closed while that in the rectum re- 
mained, thus forming an internal rectal fistula. This was treated 
in the usual way and the patient finally recovered. 

Pelvic Cellulitis ; Abscess discharges through the Saphenous Open- 
ing. — In this lady's fourth confinement calcareous degeneration of 
the placenta was found. It was retained for a long time in spite of 



PELYIO CELLULITIS. 571 

all the ordinary efforts used to deliver it ; it was found necessary to 
detach it from the uterus, a very difficult task. She did very badly 
from the beginning, soon developing a metritis and celhilitis ; she 
remained in a very precarious condition for about two months ; the 
products of the inflammation formed a large mass on the left side 
which extended up to, and finally became adherent to, the abdominal 
walls. 

Full details need not be given, suffice it to say, that at the end of 
twelve weeks an abscess opened through the inguinal canal. Much 
relief followed the opening and the copious discharge of pus, but it 
continued to discharge for weeks, and although she had improved 
after the opening of the abscess, she began to run down from this 
chronic suppuration, and her life was again despaired of. A probe 
was passed from the anterior opening and downward into the pelvis 
until its point could be felt on the left side of the cervix ; there was 
still, however, a very thick wall between the vagina and the end of 
the probe. After faithfully trying the effect of careful washing out 
and drainage, without success, a counter-opening was made through 
the vagina by means of the thermo-cautery, and a drainage-tube carried 
through the opening in the abdominal walls down into the vagina. 
This tube was injected three times a day, and as the patient improved 
quite fairly the tube was drawn down toward the vagina, leaving 
the outer opening free. JSTo discharge occurring at the abdominal 
opening and the wound showing a disposition to close, the tube was 
gradually withdrawn, and finally removed entirely. The discharge 
continued for some time after the removal of the tube, but finally 
ceased, and the patient recovered and has remained well ever since, 
a period of eighteen years. 

Pelvic Cellulitis in which the Discharge was delayed, but finally re- 
lieved by Aspiration. — The history of this case has nothing peculiar 
in it except that it progressed as cellulitis usually does, until the 
time when the abscess was expected to discharge. It failed to do so, 
and the patient's general nutrition beginning to suffer, it was deemed 
advisable to use the aspirator ; this was done and the abscess, which 
was in the right broad ligament, was emptied of about eight ounces 
of pus. This gave great relief, but in time the abscess filled again, 
and again it was aspirated, but this time before removing the needle, 
the sac was carefully washed out with carbolic acid and water. 
Great care was taken not to inject quite as much as the quantity of 
pus removed, for fear that by overdistending the abscess, some thin 
point in the sac might rupture and cause mischief. 

There was considerable reaction after this aspiration, the pulse 
38 



572 DISEASES OF WOMEK 

and temperature running up, but soon subsiding again. Nothing 
of importance occurred in the history of the case, and she recovered 
in due time. 

A Case of Cellulitis terminatiiig in Multiple Abscesses, cured by 
enlarging the Opening and breaking down the Walls of the Small Ab- 
scesses. — This case had a history during its early stages, quite in ac- 
cordance with the ordinary progress of the disease, but after suppu- 
ration and discharge the patient was not relieved, and the suppura- 
tion continued. The opening was found to be a very small one, 
situated behind and to the left of the cervix uteri. After trying 
every possible means to improve her general condition without 
effect, the opening was enlarged by dilatation, the patient being an- 
gesthetized ; after dilatation, the finger was passed up into the mass, 
and the walls of several small abscesses broken down. This was 
rather easily accomplished because the uterus and the mass of in- 
flammatory products were low down in the pelvis and within reach, 
and while the finger was passed through the opening, the other hand 
was placed upon the abdomen to act as a guide and to guard against 
breaking through into the peritoneal cavity. 

After this, the discharge was very free, and a number of shreds 
of broken tissue were evacuated. Drainage was kept up and the 
parts washed out daily until the mass had greatly diminished and 
the discharge had almost subsided. The drainage-tube was then 
removed and the patient slowly recovered. 

A Tedious Case of Cellulitis causing Septiesemia from a Very- 
Small Point of Suppuration ; treated by Laparotomy and Drainage ; 
Recovery. — This case was seen in consultation ^vith my fiiend 
Prof. Jewett, who gave me the following notes : The patient was 
thirty years old, and was confined ^larch 3, 1S85, with her seventh 
child. She had ante-partum htemorrhage and inertia of the uterus, 
wliich rendered it necessary to deliver with forceps at the superior 
strait. The nurse was incompetent, di'unk, or stupid, or all three, 
and allowed the patient and her bed to remain filthy for two days. At 
the end of the third day, the patient developed cellulitis in the left 
broad ligament ; there was also a circumscribed peritonitis limited to 
the location of the cellulitis. At the beginning of the disease, the 
temperature ran up to 103° and the pulse to 140 : this elevation was 
attained on the 7th of March, and from that time until the 15th, the 
temperature ranged between 100° and 102°, and the pulse between 
90 and 110. There was a marked difference between the morning 
and evening temperature. From the 15th until the 20th, the con- 
stitutional disturbance subsided, the local inflammation also dimin- 



PELVIC CELLULITIS. 5Y3 

ished, and there was every reason to suppose that the cellulitis 
would end in resolution. From the 20th to the 28th she was appa- 
rently convalescent, and was able to walk about, but on the 29th she 
had a relapse, the temperature running up in the afternoon to 104°. 
The following morning it was down to 97°, and from this onward 
to the 18th of April her temperature was most extraordinary in its 
variations. On the 4th and 5th it was 105° .in the afternoon and 
100° in the morning; from the 6th to the 11th it ranged between 
100° in the morning and 103° and 104° in the afternoon. All this 
also in spite of quinine and other recognized antipyretics. From 
this date to the 18th, the temperature became more irregular, occa- 
sionally dropping down to 98^°, and suddenly and at irregular times 
running up to 103° and 104°. 

It was thought that this variation of temperature was due to 
septicemia, and yet no pus accumulation could be detected in the 
pelvis. Prof. Jewett practiced aspiration with negative results, but 
subsequently made a number of appointments for further explora- 
tions ; but the patient was an exceedingly intractable one, and her 
friends had no control of her, so that he was unable to carry out his 
wishes in this regard. 

The physical signs during all this time since the relapse remained 
about the same. The patient by this time was exceedingly anaemic, 
the skin was of a bronze hue, and the digestion and general nutri- 
tion very poor, and altogether her condition was critical. 

On May 2d she submitted to an angesthetic, and Prof. Jewett 
performed laparotomy. He made an incision through the abdominal 
walls directly over the tumor in the broad ligament, and, after mak- 
ing a small puncture in the tumor, opened up the cavity with the 
finger ; no pus was found, and not more than a teaspoonful of septic 
fluid was evacuated. The cavity was drained and irrigated with a 
bichloride solution for about four weeks, when it closed completely. 

The temperature never rose above 101° after the operation, and, 
after the first three days, it became normal, and remained so ever 
afterward. She rapidly gained in her general health, and in five 
weeks had completely recovered. 

Pelvic Cellulitis ending fatally from Septicaemia. — About sixteen 
years ago, while in charge of the lying-in department of the Long 
Island College Hospital, one of my cases developed a metritis and 
cellulitis after confinement. The case progressed in the usual way, 
differing in no respect from many cases of the kind, except that 
the products of the cellulitis were unusually great. The metritis 
subsided, and the cellulitis, which was located in the left broad liga- 



574 DISEASES OF WOMEN^. 

ment, went on to suppuration, and, while I was looking for the ab- 
scess to discharge, the patient began to show signs of septicaemia. 

There was, no doubt, a large accumulation of pus in the broad 
ligament, but, as we were unable bj physical signs to determine that, 
I unwisely abstained from exploring the abscess. All constitutional 
treatment known to us was carefully employed, but the patient died. 
On post-mortem examination, a very large abscess was found in the 
left broad hgament, and nothing more. The peritonaeum covering 
the abscess was congested, and there was much subserous oedema, 
but not the slightest evidence of any peritonitis. 

This case, like many others, illustrates very well two important 
points : First, that cellalitis occurs without the slightest pelvic peri- 
tonitis accompanying it, and this fact tells strongly against those 
who make no distinction between the two affections ; and, second, 
if this case had come under my observation in recent years, when I 
appreciate the value of aspiration and abdominal section and drain- 
age, as taught by Lawson Tait (all honor to him for this !), the case 
might have been saved. 

Great progress has been made in the management of cellalitis 
within the last few years in the employment of aspiration, counter- 
openings, drainage, and abdominal section and drainage, as the above 
cases have illustrated. 

Acute Cellulitis treated by Aspiration in the Stage of Serous Infiltra- 
tion (by Yirgil O. Hardin, of Atlanta, Georgia). — " The patient was 
twenty-four years of age, and had borne a child three months before. 
The history of the patient showed that her menses had always been 
of normal character up to her pregnancy, and that she had never 
suffered from any symptoms which would indicate pelvic disease of 
any kind. Since her labor she had had tenderness of the abdomen 
and pain in walking and in micturition. Her general health, how- 
ever, had been good. On the day before I saw her she was seized 
with pain in the back, pelvis, hips, abdomen, and thighs. This pain 
was acute and excessive. Micturition and defecation became very 
painful, especially the latter. She had a slight chill, followed by 
high fever, thirst, and complete loss of appetite. When seen by 
me, she was in bed, tossing and moaning with pain, which was re- 
ferred principally to the pelvic region. Pulse, 120, temperature, 
101°, skin hot and dry, face flushed, tongue coated. Yaginal and 
rectal examination were rendered impossible by excessive tenderness 
of the parts. The following morning she was fully ansesthetized, 
and a complete examination effected. The vagina was hot and dry. 
The cervix was lacerated on the left side. The womb was low in 



PELVIC CELLULITIS. 575 

tlie pelvis, and was pushed forward against the bladder. In the 
posterior fornix, and occupying the whole space between the cervix 
and the rectum, could be felt a rounded, bulging mass, which had a 
boggy, oedematons feeling. By a finger in the rectum this mass 
could be outlined, and felt to extend upward abont an inch. J^o 
fluctuation could be detected, and, when pressed bj the finger, the 
mass could not be displaced upward. Considering the condition to 
be that of pelvic cellulitis in the stage of serous infiltration, I decided 
to attempt to draw off the serum from the cellular tissue, hoping 
thereby to abort the disease and prevent the formation of solid plastic 
exudation, with possibly a subsequent abscess. Accordingly, an as- 
pirator-needle was thrust into the tumor from the vagina at three 
different points successively, and about an ounce in all of serum 
tinged with blood was withdrawn. The tumor was then found to 
be so softened and diminished in size as to be scarcely perceptible 
to the touch. A quarter-grain of morphine was given hypodermic- 
ally, and the patient ordered to remain perfectly quiet in bed, and 
take only liquid diet. When seen twenty-four hours later, she had 
had a good night's sleep, the pain in the pelvis was almost entirely 
gone, defecation was no longer painful, appetite had returned, the 
pulse had fallen to 80, the temperature to 99°, and the patient begged 
to be allowed to get up. The mass in the posterior fornix could be 
felt only as a slight thickening. Two days later the patient was ap- 
parently in her usual health." 

Pelvic Cellulitis, with Certain Complications, which, so far as I 
know, have not been noticed or described heretofore. — The patient was 
thirty-seven years of age, and the mother of six children. She was 
confined in June, and was fairly well for five days. She got up on 
the fifth day, and tried to attend to her housework. Four days later, 
while about the house, she was taken with severe pain in the pelvis, 
and was obliged to take to her bed again. This much of her history 
was obtained from the patient. 

She was seen for the first time by Dr. J. H. Raymond about six 
weeks after her confinement, and he learned that she had had no 
regular medical care, and but very poor nursing, her poverty depriv- 
ing her of necessary attention. 

From the history and physical signs, the doctor made the diag- 
nosis of pelvic cellulitis of the left broad ligament. The tempera- 
ture at that time was nearly normal in the morning, but rose to 101° 
or 102° at night. There was marked constitutional disturbance, 
such as generally obtains in long-continued suppuration or septi- 
caemia. 



576 DISEASES OF WOMEN. 

The doctor urged her to go to the hospital, but she dechned until 
August, about ten weeks after her confinement. During the inter- 
val from the time that she was first seen until she entered the hos- 
pital she was confined to her bed with her left thigh flexed upon 
the body, and the leg upon the thigh. When she was admitted to 
the hospital she was very anaemic, had night-sweats, and had the 
general appearance of a tubercular patieut. The flexion of the leg 
and thigh continued, and there was false anchylosis of the joints. 
The tumor in the pelvis was much smaller than it had been, but 
there were pain and tenderness in the left iliac region, extending 
up to the lumbar region. The temperature ranged from 100° to 
103°, being very irregular in its rising and falling. There was no 
point in the pelvis where pus could be detected, and, although there 
was some swelling in the left side of the abdomen, no signs of pus 
could be found after repeated examinations. She was able to take 
food and stimulants fairly well, and every means was employed to 
reduce the temperatm-e and improve her strength, but without any 
favorable result. 

Hopes were entertained that the location of the suppuration 
would be found, and that relief might be obtained by aspiration or 
other means of evacuation. In spite of the constitutional treatment, 
she gradually declined, the anaemia became very marked, and the 
temperature increased, frequently being 104°, and sometimes a frac- 
tion higher. She appeared to be doomed to die of septicaemia, and, 
as a last resort, it was decided to make a laparotomy, in the hopes 
of finding the source of the septicaemia. Immediately before giving 
the ether her temperature was 104f °, pulse, 140, and feeble. 

The anchylosis of the knee- and hip-joints was with difficulty 
broken up, and then a more careful exploration of the left iliac 
region was made. There were swelling and hardening of the wall 
of the abdomen on that side, but not to any great extent. An as- 
pirating-needle was introduced at a number of points in the hope of 
finding pus, but without avail. The abdomen was opened, and a 
most careful exploration of the pelvis was made by the touch. The 
left broad ligament was considerably thickened and much less elastic 
than it should have been, showing the effect of the inflammation, 
which had subsided. Not the slightest sign of any point of sup- 
puration could be found, but, by the bimanual touch, with the fin- 
gers of one hand in the abdominal cavity, and those of the other on 
the outside, I detected obscure fluctuation, indicating that an abscess 
or sinus extended along that side of the abdomen. The location of 
the pus having been clearly marked, the wound in the abdomen was 



PELVIC CELLULITIS. 577 

closed, and an incision was made in the side down to the pus. It 
was found that the pus cavity was very small at its lower and most 
superficial end. It would not admit the little finger. This ac- 
counted for the fact that it was not found with the exploring needle. 
Passing a probe from the opening made upward, I found that the 
sinus was wider above, and extended up to the diaphragm. The 
cavity was washed out, and a drainage-tube introduced. 

Dr. Palmer, who aided in the operation, conducted the after- 
treatment, and the following facts are taken from his record, as kept 
by the house-surgeon : 

The patient reacted well under the effect of morphine and atropia, 
given hypodermically at the end of the operation, and again in three 
hours. Whisky with hot water was given four hours after the opera- 
tion ; she retained it well, and from that time onward the morphine 
and whisky were given to meet requirements. Five hours after the 
operation the temperature was 99^°, pulse, 128, respiration, 28. Two 
hours later the pulse went up to 100|^°. The night was passed very 
comfortably, but she required mgrphine and whisky in large doses, 
not altogether because of the pain or exhaustion, but largely from 
the fact that she was used to both. For years she had been a drinker, 
and, during the long illness previous to the operation, she had taken 
morphine. At five o'clock on the following morning the tempera- 
ture was 102°, but in two hours it came down to 99°. 

From this time onward her progress was favorable, at times the 
temperature went up one or two degrees, but came down when the 
pus sac was washed out. She improved in strength but the sup- 
puration high up in the cavity continued, but in a much less degree. 

Her lung-trouble progressed slowly, but she seemed doomed to 
pulmonary phthisis. One month after the operation there was still 
a little discharge from the wound, but she did not apparently suffer 
from that to any extent, but her cough was worse, and the lungs not 
improving. At this time she returned to her home. The final re- 
sults I have not yet obtained. 

The following case was similar to the above, but terminated 
fatally, and a post-mortem examination revealed the exact nature of 
the lesions. 

The patient was thirty-seven years old, and had been confined of 
her fifth child four months previous to the time that I first saw hei' 
in consultation with Dr. P. L. Dickinson. From the history that 
we could gather, she had fever from the day after her confinement, 
and had been sick ever since. She was emaciated, and her skin dry 
and dusky ; the temperature ranging from 101° to 102° ; she had 



5T8 DISEASES OF WOMEN". 

but little appetite, and was constipated. She rested on the right side 
with the legs and thighs flexed, and complained of severe pain in 
the right groin and leg. Owing to the fixed position of the right 
leg and the great pain which she suffered in moving, a physical 
examination was not easily madco The uterus was apparently nor- 
mal and movable, but high up, at or above the brim of the pelvis, 
on the right there were evidences of inflammatory products. The 
diagnosis of abscess in the false pelvis was made, causing septicae- 
mia. She was taken to the hospital, and explorations were made 
with the aspirator, in the hope of finding the exact location of the 
pus, but with negative results. Laparotomy was performed by 
Prof. Charles Jewett. The pelvic organs were normal, except that 
there were evidences of a former cellulitis in the upper portion of 
the right broad ligament. The presence of pus was made out in the 
right iliac and lumbar regions ; the abdominal wound was closed, and 
an opening made above the right groin into the abscess. It was 
found that the abscess cavity extended upward along the spine for 
twelve inches. The subsequent treatment consisted in washing out 
the abscess cavity, and supporting the patient with nourishment and 
stimulants. She did not rally well, but gradually failed, and died 
the third day after the operation. 

The autopsy showed that the abscess cavity extended from the 
right broad ligament upward behind the kidney and to the right of 
the spinal column to the diaphragm. The psoas muscle was in- 
volved in the abscess, but there was no bone-disease, and it was the 
opinion of all who attended the autopsy that the disease began as a 
cellulitis of the right broad ligament. 

A case similar to the above came under my observation twelve 
years ago. Upon being admitted, the patient gave a history of cel- 
lulitis following confinement. She was in a very low condition from 
septicaemia. I found signs of suppuration in the left iliac region, 
and, on making an incision, I found a large abscess, which extended 
upward to, if not beyond, the diaphragm. 

The patient had a cough with purulent expectoration, but no 
well-defined signs of any disease of the lungs. After washing out 
the abscess sac with carbolic acid and water, the patient declared 
that she could taste the acid ; this led me to suspect that the abscess 
had opened into one of the larger bronchi ; water colored with car- 
mine was injected, and the matter expectorated afterward was col- 
ored with the carmine. 

She died of exhaustion, and at the autopsy it was found that a sinus 
extended up behind the diaphragm ard opened into a bronchial tube. 



CHAPTER XXXII. 



PELVIC PEKITONITIS. 



The peritonaeum whicli covers the pelvic viscera of the female dif- 
fers in no respect in its anatomical construction from the general peri- 
tonaeum, and its function is the same. It differs only in the organs 
which it covers, and in the fact that there is in this region a direct 
communication and union between the mucous and serous mem- 
branes at the opening of the Fallopian tubes. 




Fia. 208. — The pelvic peritoaasum as seen on looking into the brim (Hodge). Diagramatic 



580 



DISEASES OF T70MEN. 



From the fact that the peritonseum is a continuous membranec, 
one would naturally suppose that an inflammation beginning at one 




Fig. 209. — The reflections and pouches of the pelvic peritongeum looking into the 
cul-de-sac from behind (Hodge). Diagrainatic. 

point would incline to extend to the whole membrane, so that gen- 
eral peritonitis would be the rule in the pathology of inflammation 
of this membrane. It is a fact, however, that the pelvic peritongeum 
becomes the seat of inflammation very often and without any general 
disposition to extend to the abdominal peritonaeum. The two affec- 
tions then, that is, pelvic peritonitis and general peritonitis, while 
they are the same in their patholoofy, differ so in their clinical his- 
tory and causation, as to render them two separate and distinct 
affections. 

There is a form of peritonitis which occurs after parturition, in 
which the inflammation begins in the uterus and extends to the 
general peritongeum and is known as metro-peritonitis, but this also 
differs entirely from pelvic peritonitis, which occurs far more fre- 
quently than either general peritonitis or metro-peritonitis. 

The pathology of pelvic peritonitis is the same as in inflamma- 
tion of serous membranes generally. There is flrst, subserous con- 
gestion, followed by a transudation of blood serum, and then an 
exudation of plastic material, or the higher organized constituents of 



PELVIC PERITONITIS. 581 

tlie blood. Ordinarily, this ends the formative stage of the inflam- 
matory process, and the products of the inflammation are disposed of 
first, by the absorption of the serous transudation and the organiza- 
tion of the exudate. This organization simply consists in the devel- 
opment of blood circulation, either in or beneath the exudate, suffi- 
cient to maintain it in a vitalized condition and prevent its further 
degeneration and disintegration. 

The peculiar characteristic of this exudate is to form adhesions 
to adjoining tissues and to undergo contraction in its after-life, so 
that following an attack of pelvic peritonitis, the parts in the grasp 
of the exudate become adherent, and are often drawn out of their 
normal position by its contraction. Occasionally, but rarely, the in- 
flammation of this serous membrane goes on to suppuration. When 
this form of peritonitis takes place, pus accumulates usually in the 
sac of Douglas ; there it sometimes is w^alled in by an exudation of 
lymph which unites the two folds of the peritongeum which form 
the sac. Occasionally, too, small abscesses may be formed in the 
exudate which is thrown out around the ovaries and Fallopian tubes. 

There is a wide range in the degree of severity in cases of pelvic 
peritonitis ; in some, a circumscribed spot of inflammation may oc- 
cur which gives rise to a little discomfort at the time, and, passing 
off*, leaves no suspicion that there ever had been an inflammation 
there. These cases we know occur from the fact that the traces of 
inflammation are found post-mortem. 

From these circumscribed and exceedingly mild attacks, we find 
all grades of severity, up to the most marked, where the whole pelvic 
peritonaeum is involved and suppuration occurs, and the case termi- 
nates fatally. In this respect, pelvic peritonitis strongly resembles 
pleurisy, the milder cases representing the circumscribed, dry pleu- 
risy, and the more severe corresponding to that of pleuritic em- 
pyema. 

There is also another form of pelvic peritonitis, in which there 
is an unusual transudation of serum which accumulates in the sac of 
Douglas, and corresponds to the ordinary pleurisy wdth effusion. 

Judging from the number of cases of peritonitis met in practice, 
and also from observations made post-mortem, this is one of the 
pelvic diseases which occurs perhaps as frequently as any; cer- 
tainly, it is much more common than pelvic cellulitis uncomplicated. 
It no doubt occurs quite frequently or occasion alh^ in the progress of 
other pelvic affections, like cancer of the uterus, pelvic cellulitis, sal- 
pingitis, etc., but under these circumstances, it is a secondary affec- 
tion, and in that form need not be discussed here. 



582 



DISEASES OF WOMEN. 



In less severe cases the exudation gradually disappears, and the 
mobility and functional activity of the pelvic organs may be again 
restored and the patient may be considered as having recovered. 
But this takes a long time before it is accomplished. When pelvic 
peritonitis terminates fatally, it usually does so because the inflam- 
mation has gone on to suppuration, and may be called a pm'ulent 
peritonitis, and in that case the patient may die in a few days from 




Blase 



Fig. 



210. — Eetroverted uterus bound back by peritonitic adhesions 
(Winckel.) 



a, 6, adhesions. 



the time of the attack, either from shock or acute septicaemia, or 
both, or inflammation may extend to the general peritonaeum, and in 
that way sacrifice the patient. 

Causation. — In regard to the causes of pelvic peritonitis, we find 
that non-parous women are most liable to it, especially those who 
suffer from imperfect development of the sexual organs and de- 
rangement of their functions, like dysmenorrhoea, for example. 

The immediate causes of pelvic peritonitis are of three kinds : 
First, where it is secondary, and evidently caused by some affection 
or inflammation of some of the other pelvic viscera, like ovaritis, 
salpingitis, and endometritis. Second, traumatic influences, such as 
injuries of any kind, imprudence during menstruation, and all sur- 
gical operations or treatment. In those who have suffered long 
from displacements and flexions of the uterus and general irritability 
and congestion, injuries appear to be sufficient to set up a peritonitis, 
like the passing of a uterine sound, or the application of caustics to 
the uterus. Third, specific causes, such as the escape of septic mate- 
rial from the Fallopian tubes, in cases of endometritis and salpin- 
gitis, but more especially, the virus of gonorrhoea. In a large num- 
ber of cases the cause will be found in this specific virus ; this is 
the reason why pelvic peritonitis is such a common affection among 
prostitutes. 



PELYIO PERITONITIS. 583 

The duration, termination, and after-conseqnences of pelvic peri- 
tonitis, depend largely upon the extent of the inflamraation and the 
cause which gives rise to it. In some cases where the exudation is 
limited recovery will take place in a few weeks, and but little after 
ill effects will be noticed, except occasional pain from time to time 
in the region of the exudate. In other cases where the whole pel- 
vic peritonaeum is involved, the fimbriated extremities of the Fallo- 
pian tubes become involved in the exudate, and are virtually de- 
stroyed. If this includes both sides, the function of the ovaries 
and tubes is arrested because of the damage to the structure. 

Degeneration of the ovaries often follows under these circum- 
stances ; sometimes they become inflamed and succulent ; at other 
times they become atrophied, due, no doubt, to the pressure of the 
contracting exudate and the interruption of the circulation in them ; 
in short, in some of these cases, the adhesions and the quantity of 
exudation so destroy the anatomical relations that on post-mortem 
it is almost impossible to recognize the tissues or organs. A mass 
of tangled adhesions and products of inflammation covering the 
uterus and broad ligaments, is about all that can be made out. 

When such patients live, they suffer greatly from pelvic pain 
and dysmenorrha3a, if the function of menstruation is not arrested, 
as it sometimes is, by the destruction of the ovaries. 

Symptomatology, — This varies according to the severity of the 
attack ; in average cases there is a well-defined symptomatic fever, 
the pulse being characteristic of inflammation of the serous mem- 
branes, being small and wiry, and running up from 110 to 130 ; the 
temperature is variable, often running to 103° F. and 104° F., and 
in severe cases to 106° F. 

At first, the skin is usually dry and hot ; there is marked de- 
rangement of the digestive organs, nausea and vomiting often occur- 
ring ; sometimes in the severer cases vomiting of that greenish ma- 
terial so common in general peritonitis, occurs. There is usuallv 
marked tympanitic distention, and the patient prefers resting quietly 
on the back with the limbs drawn up, a position which seems to be 
the easiest ; there is usually a considerable disturbance of the nerv- 
ous system, the patient being anxious, restless, and the facial ex- 
pression showing anxiety and dread. Sometimes there is delinum, 
but not usually, and when it does occur, I am inclined to think it 
shows that the ovaries are affected ; at any rate, and in several cases 
that I have seen, where I have every reason to believe that the ova- 
ries were also inflamed, there was great mental excitement, and tem- 
porary insanity in some. 



584: DISEASES OF WOMEN". 

The pain in the pelvis is usually acute, much more so than in 
cellulitis, and there is great tenderness to the touch ; the pelvic ves- 
sels are generally affected, and there is marked rectal tenesmus, aod, 
if the peritonaeum in front of the uterus is involved, there is vesical 
tenesmus also ; in fact, this vesical irritation is often an exceedingly 
annoying symptom. 

The physical signs obtained by a vaginal examination during the 
first stage simply reveal tenderness with some apparent thickening 
of the roof of the pelvis. This may be limited to one portion of the 
pelvis, but in well-marked cases it extends throughout. When exu- 
dation has taken place, complete fixation of the uterus is found, 
and the roof of the pelvis, as felt through the vagina, presents the 
extreme hardness which is characteristic of peritonitis, and has been 
called the dealboard hardness by some. If nmch lymph is thrown 
out, especially if it is associated with considerable serum, a mass will 
be found behind the uterus occupying the sac of Douglas. At no 
time, however, do the products of this form of inflammation extend 
above the superior strait, unless as an exceedingly rare exception ; 
in case that the disease goes on to the formation of pus, a well-de- 
fined tumor may be found in the sac of Douglas, and if this pus is 
discharged, the intense hardness at that point may disappear in part ; 
but if the entire exudation is lymph, it remains hard for a long 
time. There is almost always a displacement of the uterus as well 
as a marked fixation, and this fixation is likely to remain also ; as 
contractions occur subsequently the position of the uterus may be- 
come changed, and not only is the organ thus displaced, but it is 
fixed in this position. 

The difference between the physical signs of pelvic peritonitis 
and other diseases of the pelvic organs, such as cellulitis and pelvic 
hgematocele, will be given in treating of the signs of the latter. 

Treatment. — The objects to be attained in the treatment of pel- 
vie peritonitis, are first, to control or limit the inflammation so far 
as possible, and to relieve the pain which is usually very great ; by 
accomplishing the latter, we do all that is possible to effect the 
former, the means employed to relieve pain, fortunately, having the 
greatest control over the inflammation. The great remedy then in 
the earliest stages of pelvic peritonitis, is opium ; Alonzo Clark was 
the first to discover the value of this agent in general peritonitis, 
and to him we owe most of our knowledge of the management of 
this affection, and it is equally available (that is, the opium treatment) 
in pelvic peritonitis. 

The quantity of opium to be given should be measured by the 



PELVIC PERITONITIS. 585 

effect obtained ; the pain should be relieved and kept in abeyance 
by the regular administration of doses sufficient to accomplish this 
object ; when it is possible, opium or morphine should be given by 
the mouth, because in this way the patient can be kept more uni- 
formly under its influence ; it often happens, however, that the 
stomach is too irritable to retain it at the outset ; the morphine 
should then be given hypodermically until the stomach is quiet. In 
some cases where there is marked pelvic tenesmus, the opium may be 
given by the rectum ; it should then be given in solution or enema, 
because if administered in suppositories it is too slightly absorbed. 

Sometimes in giving the opium in this way it will aggravate in- 
stead of relieving the pelvic tenesmus, which is often an exceedingly 
annoying symptom. In many cases the patient has a constant de- 
sire to urinate, but all efforts to do so only increase greatly the suf- 
fering ; this induces the patient to resist the desire, so that there is 
a vesical tenesmus with retention ; under these circumstances great 
relief can sometimes be given by the careful use of the catheter. 
Warm applications may be made to the abdomen in the form of 
fomentations ; counter-irritation, also, is often useful, which may be 
obtained by the use of mustard-pastes, turpentine stupes, etc. 

The bowels should be kept quiet for a few days by the use 
of opium until the acute stage has passed, when they should be 
relieved by the mildest possible means. If the patient is seen at 
the very onset of the attack, and the rectum is found to be dis- 
tended, it should be emptied at once by enema ; during the early 
part of the first stage, if the stomach is, as it usually is, very irrita- 
ble, but little will be accomplished in the way of giving nourish- 
ment ; the thirst may be alleviated by giving ice or minute 
quantities of effervescing waters. If there is great prostration, a 
little champagne and Apollinaris water or carbonic water may be 
given to relieve the thirst and sustain the patient. As soon as the 
stomach will admit of it, nourishing food, mostly fluid, should be 
given ; the beef-extracts, digested milk, and gruel will usually an- 
swer the best purpose. At the end of the acute stage, when the 
pain is subsiding or relieved, and the temperature and pulse are 
down, then the opium can be greatly reduced in quantity, or given 
up entirely if the patient sleeps well ; usually, however, small doses 
will be required at night to secure rest. 

The next object in the treatment is to favor a furtlier limitation 
of the plastic exudation, and to promote the absorption of the in- 
flammatory products ; this can be accomplished, if at all, by the use 
of counter-irritation. Small blisters applied in the iliac regions, and 



586 DISEASES OF WOMEN. 

repeated, often give the patient relief from disturbance, and appar- 
ently favor the absorption of the inflammatory products. The best 
method of employing blisters under these circumstances is to apply 
two, one on each side, to be kej)t there until the skin is thoroughly 
vesicated, then puncture the vesicle and let out all the serum and 
allow the cuticle to fall down upon the cutis, and then apply over 
this absorbent cotton, and allow it to remain undisturbed until heal- 
ing is complete, w^hicli usually takes place in from two to four days ; 
blisters may again be applied in the same way. During this time 
the patient should be sustained by nourishment and tonics, quinine 
being one of the most reliable agents. When all acute symptoms 
have subsided and there is no evidence of any serum or pus accu- 
mulated in the pelvis, the further disposition of the inflammatory 
products may be favored by the use of iodine. The tincture of 
iodine may be applied through the speculum to the roof of the pel- 
vis, that is around the cervix uteri and upper part of the vagina, 
and iodide of iron may be given internally. Counter-irritants from 
time to time should be continued, one part of croton-oil dissolved 
in two parts of sulphuric ether to which are added three parts of 
tincture of iodine, makes a good application for keeping up continu- 
ous irritation ; this should be painted over the lower portion of the 
abdomen, and repeated when the fine eruption which it produces 
has disappeared. 

These remedies should be changed after a time to the iodide of 
potassium or the bichloride of mercury with chloride of iron, the 
latter being the most valuable as a tonic and alterative. While there 
are still some of the products of inflammation remaining in the pel- 
vis, or at least for a long time after the subsidence of the acute in- 
flammatory symptoms, the greatest possible care should be taken to 
guard the patient against undue labor ; standing, walking, or riding 
may produce a relapse, and hence, the patient should be made to 
carefully feel her way in sitting up and in taking exercise ; especially 
should this care be insisted upon at the menstrual periods. 'No 
rules can be laid down with reference to this except that any exer- 
cise which excites pain should be avoided ; short stages of exercise, 
followed by rest in the recumbent position, should be adhered to, a 
little more liberty being given every day, in case it does not pro- 
duce pain. 

All exercise of the sexual functions should be prohibited until 
pain and tenderness have subsided. In case there is an accumula- 
tion of serum or pus in the sac of Douglas, this should be removed 
by aspiration ; if pus is found, the cavity should be washed out 



PELVIC PERITONITIS. 58T 

with a weak solution of carbolic acid and water, or of bichloride of 
mercury, and if this does not relieve the pain, an opening may be 
made and drainage established, but this is usually unnecessary. 

ILLUSTRATIVE CASliS. 

A Typical Case of Uncomplicated Pelvic Peritonitis. — A lady 
twenty-hve years of age, who had been married for two years, and 
was sterile, began to menstruate first at fifteen, and had also had 
dysmenorrhoea slightly for the first years of her adult life, but it was 
much aggravated after her marriage. She was subject to attacks 
of pelvic pain, though not severe, after much exercise. At the time 
of the attack now under consideration, she was menstruating, and 
went out into company, and, I believe, engaged in dancing, slu] 
took cold on her way home. In the night she was seized with vio- 
lent pain in the pelvic region, with nausea and vomiting. She was 
seen early in the morning, and her temperature was found to be 
102° F., and her pulse 120 ; it was also observed that she was a 
feeble-looking person of a tubercular diathesis ; there was much ten- 
derness to the touch in the lower portion of the abdomen, and also 
considerable tympanitic distention. On digital examination, there 
was evidently an increase in temperature, with congestion and 
marked tenderness in the region of both broad ligaments and behind 
the uterus. There was no fixation apparent nor hardening of the 
tissues, but, owing to the increased tenderness, it was difiicult to 
make a very critical examination. The rectum was distended with 
fecal matter. A hypodermic injection, consisting of ten minims of 
Magendie's solution of morphia, was given, and warm water was 
injected into the rectum ; the immediate effect of the enema and 
evacuation was to increase the pain, and in two hours afterward it 
was necessary to give five more minims of Magendie's solution hy- 
podermically ; this gave considerable relief, but it did not produce 
sleep. In the middle of the day she was found to be still restless, 
with an anxious and somewhat pinched expression, and expressed 
herself as fearful of some dangerous trouble. Another hypodermic 
injection was given, because she still had nausea, but no vomit- 
ing ; late in the evening she was still in much pain, having come 
partially out from under the influence of the opium ; she was still 
nauseated, and her temperature was 103^}° F., and her pulse over 
120 ; she complained of some headache, felt hot and feverish, and 
yet she was in a perspiration. Fifteen more minims of Magendie's 
solution was given, which secured for her several hours' sleep. 
Early in the morning she was found wakeful and restless, and the 



588 DISEASES OF WOMEIN". 

pain had returned; her stomach still being irritable, another ten 
minims of Magendie's solution of morphia were given ; during the 
night, while awake, small pieces of ice were given, which were grate- 
ful to her, but she was still thirsty, and begged for a large drink 
of cold water ; she was given half a wine-glass of cold Yichy every 
half -hour when she desired it ; she retained some of this, and in the 
forenoon took a little clear coffee, which she relished and retained. 
She still continued to suffer from nausea, great abdominal tender- 
ness, and considerable pelvic pain ; she also complained of a very 
urgent desire to urinate, but any effort to do so gave her so much 
pain that she resisted the desire ; the nurse was directed to pass the 
catheter, which she did, and drew off less than half a pint of urine 
of a remarkably dark color. At night she again had fifteen minims 
of the solution of morphia, which gave her a few hours' sleep, when 
she ^gain awoke with pain ; ten minims was then given, which car- 
ried her through the night fairly comfortable. 

On the third day after the attack, upon digital examination, the 
parts of the portion of the pelvis within reach were found to be hard, 
and the uterus fixed. The hardness and fixation extended entirely 
across and behind the broad ligament and the uterus ; a diagnosis of 
pelvic peritonitis was then made \vithout hesitation. The nausea at 
this time was, less marked, so that she retained the Yichy- water and 
coffee and tea, and occasionally a little beef-tea ; but these were ad- 
ministered in small doses, care being taken not to give her the Yichy 
immediately before or after she took any of the others. 

Every little change in the temperature was observed at this time. 
It had required from forty-five to fifty minims of Magendie's solu- 
tion to keep her comfortable during the twenty-four hours up to the 
end of the third day ; after that the opium was given by the mouth, 
twenty minims of Squibb's liquor opii comp. were given every three, 
four, or six hours, according to the disturbance or pain which she 
had, and from twenty-five to thirty minims at bed-time. This was 
sufficient to keep her tolerably comfortable, and to secure a sufficient 
amount of sleep in the night and an occasional nap during .the day. 
About this time she suffered very much from tympanitic distention ; 
occasionally she could raise gas from the stomach, but this gave her 
very little relief. On the fifth day six grains of quinine, dissolved 
in sulphuric acid, and added to an ounce of sirup of acacia and a 
little warm water, was given by enema ; this was retained, and pro- 
duced partial relief from tympanitic distention. 

About a week from the time of the attack the pelvic peritonaeum 
was evidently covered with a marked exudation, especially that por- 



PELVIC PERITOmXIS. 589 

tion forming the sac of Douglas, while the fixation and induration 
involved the entire roof of the pelvis ; it was most marked behind 
the uterus, extending down to a point on a level of the surface of 
the cervix uteri. 

On about the eighth day a marked improvement had taken place 
in her general condition; the temperature was 101^^° F., and the 
pulse a little above 100 ; her tongue was still thickly coated, but was 
beginning to clean off on the end and sides ; the nausea had mostly 
subsided, but she had no appetite ; she was able, however, to take 
a fair amount of fluid nourishment — beef -extract, digested gruel, and 
milk, with a little tea and coffee from time to time ; she still had 
thirst, and took considerable water. We were able at this time to 
reduce the quantity of liquor opii comp. about five drops every three 
or four hours, with twenty-five drops at bed-time. At this time we 
began the use of small blisters, and continued to keep the lower por- 
tion of the abdomen in a state of irritation for the next ten or twelve 
days ; she was also given a pill three times a day, composed of one 
grain of quinine, one tenth of a grain of extract of belladonna, one 
half grain of comp. extract of colocynth, and one fourth grain of 
ipecac ; this, after a couple of days, excited some peristaltic action of 
the bowels, and, after an enema of soap-suds, the bowels moved. This 
relieved the tympanitis considerably, and, although she felt greatly 
distressed immediately after the movement of the bowels, she was 
apparently better for it. 

All this time she had a good deal of irritation of the rectum and 
bladder, and a constant sense of fullness and distress in the pelvis, 
with pain that varied very much in severity. From this onward 
she suffered very little, although obliged to keep quiet in bed ; she 
continued to take a fair amount of nourishment and solid fo^, such 
as rare steak and a chop, which with toast and milk, were added to 
her bill of fare. 

The quantity of opium was diminished until she only took one 
dose at bed-time ; the pills were continued, and the bowels moved 
every third day by enema ; the temperature had now come down to 
100° F., and the pulse to 95, but there was still very little appai'ent 
difference in the condition of the pelvis. This line of treatment, 
including the counter-irritation, w^as continued until the end of the 
third week ; at that time she was permitted to sit up a little in bed, 
and was able to turn from side to side without much discomfort. 
She continued in this way for three days longer, when the pain 
began again, and the pulse and temperature ran up ; her stomach 
became again disturbed, although there was no vomiting, and the 



590 DISEASES OF WOMEN. 

opiam had to be given in small doses more frequently, in order to 
relieve her — in short, there wa.s every appearance of a lighting up 
of the acute trouble, but the temperature did not go beyond 101° F., 
or the pulse beyond 110, and she was exceedingly irritable, nervous, 
and despondent at this time ; the menstruation then came on, and 
after a day her pain began to subside a little, and at the end of the 
third day her condition was about what it was before the relapse 
took place. This undoubtedly was simply a dysmenorrhoea from a 
lighting up of the inflammation. 

After the menstrual flow subsided, she improved in her general 
condition very decidedly, and, at the end of the fifth week from the 
beginning of the attack, she was able to sit up a little while in bed, 
and to be occasionally lifted into her reclining-chair. Her tempera- 
ture and pulse were nearly normal, but she was quite weak, and still 
had some disturbance in the region of the pelvis ; milder forms of 
counter-irritants were employed, occasionally using a mild mustard- 
paste, and sometimes painting with the tincture of iodine ; she was 
then put under general tonic treatment, including quinine and 
iron. 

The bowels were kept regular by the pills which were prescribed 
before. At this time there was still marked fixation and induration 
in the location of the pelvic peritonaeum, and from this onwai'd the 
treatment consisted in good, generous nourishment, wine, and tonics ; 
the iodide of iron alternated with bichloride of mercury and chloride 
of iron was continued off and on for about six months ; at the end 
of that time her health was about as good as it was before she was 
taken ill, although she suffered more from her dysmenorrhoea than 
formerly, and was obliged to keep in bed during the menstrual 
period. About this time an examination was made when the indura- 
tion had partly disappeared, but not wholly ; there was still fixation 
of the uterus, and efforts were now made to relieve her dysmenor- 
rhoea, which was evidently due to an anteflexion of the body of the 
uterus, by enlarging the canal by gradual dilatation ; the first at- 
tempt at this, however, gave rise to so much pain and suffering that 
no further efforts were made in that direction at that time. A vag- 
inal douche of hot water was ordered, but that did not give her 
any apparent relief, nor did it appear to influence the disposition of 
the inflammatory products. Tincture of iodine was applied arouud 
the cervix uteri and upper portion of the vagina once a week for a 
month or two, and this appeared to be beneficial ; at least she im- 
proved while this was being employed, but I presume that the con- 
stitutional medication had most to do with her progress — in fact, my 



PELVIC PERITONITIS. 591 

experience with this ease and nianj others has satisfied me that local 
treatment in old cases of pelvic peritonitis does harm ten times to 
once that it does good. She was kept upon her general tonic and 
alterative course of treatment for six months after suspending all 
local treatment, and then it was found that there was a marked im- 
provement in the local condition ; as soon as the slight mobihty of 
the uterus was established, the induration and fixation much more 
rapidly diminished. 

The patient passed from under my observation, but returned 
again in two years to be treated for dysmenorrhoea, and I then had 
an opportunity of examining her carefully, and found considerable 
mobility of the uterus, and also of the broad ligament ; the marked 
induration had wholly disappeared — in fact, the only trace of her 
former peritonitis remaining was a small mass in the most dependent 
part of the sac of Douglas ; this did not appear to give her any 
trouble ; there was also less anteflexion of the body of the uterus. 
I was then able to treat her for her dysmenorrhoea, and succeeded 
in relieving her to some extent, but not wholly. Four years after 
I heard of this patient, and she had still maintained fair health, but 
suffered slightly at her menstrual periods. 

A Case of Circumscribed Pelvic Peritonitis of the Mildest Charac- 
ter. — A young lady of somewhat delicate organization, who had suf- 
fered from irregular and painful menstruation, was seized about the 
time of one of her periods with violent pain in the left ovarian re- 
gion ; she was out at the time the pain came on, and I believe was 
overfatigued ; she returned home and went to bed, and I saw her 
several hours afterward ; she then had tenderness on deep pressure 
in the left iliac region and also had pain there of an acute character. 
Her temperature was below 100° F., but her pulse was over 100 ; she 
was somewhat nervous and restless ; I gave her a dose of bromide of 
sodium with a few minims of liquor opii comp., and ordered it to be 
repeated during the night if she did not sleep. 

One more dose was necessary to give her a comfortable night, 
and in the morning w^hen I saw her there was no constitutional dis- 
turbance except a loss of appetite and some flatulence ; her pulse 
was a little rapid and there was still pain and tenderness, but not 
marked, in the left side. In the evening of that day her menstrual 
flow began and continued normally though more free than usual ; this 
improved her condition somewhat, and although she continued in 
bad for about a week on account of the return of pain upon trying 
to sit up, still she made a good recovery, and was around as usual 
the week following. For a number of weeks she had occasional at- 



592 DISEASES OF WOMEN^. 

tacks of pain and tenderness on that side, especially at her men- 
strual periods. 

This attack passed off, and she was in fair health until three 
years afterward, when from exposure she contracted double pneu- 
monia, of which she died. The physician who attended her at that 
time obtained a post-mortem examination, and, knowing that she had 
been a patient of mine at former times, invited me to be present ; 
nothing of interest being found in the thorax I suggested the pro- 
priety of examining the pelvic viscera in the hope of determining 
the pathological conditions which gave rise to her irregular and 
somewhat painful menstruation. I had at this time entirely forgot- 
ten the attack above described, and only remembered it when we 
found the products of the pelvic peritonitis on the left broad liga- 
ment. The fimbriated extremities of the Fallopian tube were 
matted together by the old exudate, and the peritongeum covering 
the outer portion of the tube and extending downward showed evi- 
dence of an old inflammation ; the ovary, however, did not ap)pear to 
be affected, except that two or three fimbriae of the tube were ad- 
herent to it. This case illustrates the circumscribed mild form of 
pelvic peritonitis which occurs quite frequently no doubt, but is 
overlooked, except when foimd at post-mortem. 

Septic Peritonitis Terminating Fatally. — This case illustrates the 
other extreme from the one just related. A strong, healthy servant- 
girl had leave of absence on Saturday, and staying out too late, 
tried to save time by crossing a field instead of taking the road 
home ; and upon jumping a fence near the house, she was sud- 
denly seized with the most violent pain in the pelvis ; she reached 
home with great difiiculty, and was helped to bed by her fellow-serv- 
ants ; nausea, and vomiting came on, and she became pale, faint, and 
covered with cold, clammy perspiration ; the physician of the fam- 
ily. Dr. Woodruff, was sent for in the night, and by the judi- 
cious use of morphine hypodermically and stimulants administered 
by the rectum, he succeeded in bringing her out of her state of par- 
tial collapse. Her temperature then rapidly ran up to 105° F., and 
her pnlse to 130 ; there was extreme tenderness of the abdomen 
and distention ; the vomiting continued so persistently that it was 
impossible to administer nourishment or medicine by the mouth. 
The physician made a diagnosis of peritonitis which he believed to 
be general, and I saw her with him in the morning and, concurring 
in his diagnosis, we continued the use of opium, but her pulse had 
improved and the stimulants were suspended. The temperature and 
pulse continued very high and her general appearance was more like 



PELVIC PERITONITIS. 598 

that of a case of pueqDeral peritonitis than any other, but there was 
still some hope entertained of saving her until Tuesday afternoon 
when she began to vomit that greenish material so often seen in gen- 
eral peritonitis. 

Her pulse became feeble and very rapid; her temperature in 
the vagina ran up to 106° F., and she appeared like one passing into 
a state of collapse. She became more and more depressed, and died 
of shock on Wednesday morning. The case being somewhat un- 
usual, a grave question was raised as to the causation ; and hence a 
most careful post-mortem examination was made. 

On opening the abdomen w^e found that a few coils of the small 
intestine had dipped into the upper part of the pelvis, and were ad- 
herent by recent soft exudate to the upper part of the uterus. The 
sac of Douglas was found nearly full of pus, and the whole pelvic 
peritonaeum was covered with the products of acute inflammation. 
On carefully removing the pus and some soft lymph from the sac of 
Douglas and broad ligaments, a recent opening was found in one of 
the ovaries which led to a cyst not larger than a hazel-nut ; in this 
cyst were found a few drops of brownish-looking fluid which was 
preserved for microscopical examination. 

The general peritonaeum, except that covering the intestine 
which rested upon the uterus, was perfectly normal. Nothing else 
abnormal was found in any of the organs of the body ; the heart 
was rather below the average size, and so were the blood-vessels ; 
beyond this all was normal. 

It is clearly evident that this girl had small ovarian cysts, the 
contents of which were highly septic, and when the rupture occurred 
this fluid set up peritonitis, which being highly septic in character, 
developed the violent attack which overwhelmed the patient's nerv- 
ous system. 

A Case of Pelvic Peritonitis caused by Gonorrhoea, and followed by 
Pyosalpinx. — This lady was twenty-six years of age, and had always 
enjoyed very good health until she was married. Two years after 
her marriage she was suddenly taken with acute vaginitis and ure- 
thritis ; she then came under my care, and I then made a diagnosis 
of gonorrhoea and subsequently procured unmistakable evidence from 
her husband that such was the nature of the attack. 

The vaginitis and urethritis yielded promptly to treatment, and 
she was dismissed apparently well, but returned to state that she still 
suffered from uterine leucorrhoea ; I then found a well-marked cerv- 
ical endometritis with some remaining vaginitis of the upper portion 
of the vagina. While she was under treatment for this she suddenly 



594 DISEASES OF WOMEN. 

developed a pelvic peritonitis, wliich was not especially severe but in 
whicli there was considerable exudation, as indicated by the fixation 
and induration of the pelvic organs. Under ordinary treatment she 
progressed fairly well, but the case was unusually tedious. At the 
end of the year 1 considered her well, but she still had some pelvic 
pain occasionally, although the products of the inflammation had 
been almost entirely disposed of, so that there was mobility of the 
pelvic viscera and very little hardening of the parts except in the 
sac of Douglas where there still remained some of the old exudate 
which presented a somewhat irregular, nodulated condition to the 
touch. At this time she was again taken ill with the symptoms of 
another attack of pelvic peritonitis ; the pain and tenderness on this 
occasion, however, were limited to the left side, and a tumor was 
soon developed which was elastic to the touch ; this led me to sus- 
pect that this was a case of salpingitis instead of peritonitis, and 
when the acute symptoms subsided somewhat, I .endeavored to con- 
firm ray suspicions by aspirating the tumor ; I found pus and was 
able to draw off about an ounce and a half of it ; the sac soon filled 
up again, and she suffered a great deal of pain and constitutional 
disturbance, evidently due to a slight septicsemia. 

As the case was one of long duration, she became discouraged 
with my treatment at this time, and on the advice of friends, went 
to the hospital. I learned afterward, that while in the hospital she 
was operated upon, the distended tube being removed after the 
manner of Lawson Tait. 

A Case of Pelvic Peritonitis, followed by Permanent Displacement 
of the Uterus, Dysmenorrhoea, and Cystitis. — This was a married lady, 
about twenty-nine years of age, who had suffered most of the time 
from dysmenorrhoea and sterility, caused by anteflexion of the body 
of the uterus with slight retroversion. During the treatment for 
this malformation of the uterus she was attacked with pelvic peri- 
tonitis, the exciting cause being a rather forcible effort to correct 
the retroversion. The pelvic peritonitis ran its ordinary course, and 
terminated in recovery; but afterward the uterus was found in a 
markedly retroverted condition, and bound down to the posterior 
wall of the sac of Douglas ; the bladder was also drawn backward 
with the uterus, and held in that position. This gave rise to dys- 
menorrhoea quite as marked as that from which she suffered before 
her peritonitis. The malposition of the bladder caused by the ad- 
hesions rendered it impossible to completely empty that organ, and 
the partial retention of the urine developed a very troublesome 
cystitis. 



PELVIC PERITONITIS. 695 

All efforts to restore the uterus and bladder to their normal po- 
sitions were without avail. The dysmenorrhoea was partly relieved 
by treating the cervical endometritis, which she also had, and dilating 
the internal os a little. The cystitis was controlled by long-continued 
local treatment, but she still suffered from some pelvic tenesmus, 
and, in fact, remained something of an invalid during the five or 
six years that she remained under my observation. 

Pelvic Peritonitis, which went on to Suppuration, the Pus accumu- 
lating in the Sac of Douglas ; treated by Aspiration ; and Recovery. — 
This patient was a lady who had married and had borne two chil- 
dren, became a widow, and married a second time, and who had 
contracted gonorrhoea, which led to a severe attack of peritonitis. 
There was nothing peculiar in the clinical history of the case, except 
that it was very severe, but she progressed fairly well up to the time 
when the acute symptoms should have disappeared. Her tempera- 
ture and pulse continuing high, and her general nutrition showing 
evidence of some septic influence, it was presumed that pus had been 
developed somewhere in the pelvis, and, as there was a large tumor 
or a well-defined mass in the sac of Douglas, the aspirating-needle 
was introduced in the hope of finding the location of the suppura- 
tion. 

Over two ounces of sero-purulent fluid were drawn off, which 
improved the patient's condition almost immediately ; she had less 
pain afterward, her pulse and temperature improved, and her gen- 
eral nutrition also ; this improvement, however, was only for a short 
time, when the former symptoms returned, and aspiration was again 
practiced with the result of finding a small quantity of pus. The 
sac was at the same time washed out with a solution of bichloride 
of mercury, and from this onward she did well, although she did 
not fully regain her original health ; she still had attacks of pelvic 
pain at times, and active exercise usually brought on pelvic tenes- 
mus. The last time that she was examined, about a year and a half 
from the time of the pelvic peritonitis, there was still considerable 
fixation of the pelvic organs and induration, showing that the prod- 
ucts of the bygone inflammation had not by any means been all dis- 
posed ol 



89^ 



CHAPTEK XXXIII. 



PELVIC HEMATOCELE. 



Pelvic hsematocele is, as the term indicates, an accumulation of 
blood in the pelvis, or, more strictly speaking, in the sac of Douglas, 
or else in the cellular tissues of the pelvis. Of course, the accumu- 
lation of blood is merely the result of some other lesion, and conse- 




FiG. 211. — Subperitoneal pelvic hsematoeele. U, displaced uterus ; B, empty bladder. 



PELVIC HEMATOCELE. 



597 



qiientlj pelvic hsematocele is secondary to the lesion which gives 
rise to it. 

There are two forms of pelvic hsematocele, distinguished accord- 
ing to the location of the accumulation of blood : Subperitoneal 
pelvic hgematocele, or that in which the haemorrhage occurs in the 
cellular tissues (Fig. 211), and intra-peritoneal hgematocele, in which 
the blood accumulation is in the pelvic cavity — that is, in the sac of 
Douglas (Fig. 212). 

The subperitoneal variety is not always a very serious affection, 
while the intra-peritoneal variety is one of the most dangerous dis- 



UlCt-il 




Fig. 212. — Intraperitoneal pelvic hE\?matocele. 

eases which comes under the observation of the gynecologist ; there- 
fore, the former will be dismissed with a few remarks later, while 
the most of what follows will refer to the intra-peritoneal variety 
wholly. 

The sources of the hsemorrhage giving rise to this aUection 
which have so far been accurately determined are from rupture of 
blood-vessels of the ovaries or veins of the broad ligaments, and 
from rupture of an aneurism of some of the pelvic arteries, reflux 
of blood from the uterus or Fallopian tubes, and general transuda- 



598 DISEASES OF WOMEN. 

tion from the smaller blood-vessels in certain conditions of tlie blood, 
such as that of purpura, for example. Rupture of the sac in cases 
of extra-uterine pregnancy has also been mentioned as a source of 
hgemorrhage, giving rise to pelvic hasmatocele. But, as extra-uterine 
pregnancy is a matter wholly by itself, it need not be considered in 
this connection. It will be seen from this that the conditions which 
give rise to haemorrhage may all be classed under two heads — first, 
some condition of the blood-vessels which favors their giving way, 
and, second, the conditions of the blood, which favor haemorrhage, 
such as we find in persons of the hsemorrhagic diathesis. 

The extent of the accumulation depends to some extent upon 
the size of the ruptured vessels. If the haemorrhage is extensive, 
the loss of blood and shock may cause a fatal termination in a few 
hours. This shock is due to the impression made upon the peri- 
tonaeum by the sudden effusion of blood, which acts as a foreign 
body. If this does not occur, and the haemorrhage ceases, then pel- 
vic peritonitis, sometimes general peritonitis, supervenes, and the 
products of the inflammation are thrown around the blood-clot, and 
in this way it becomes walled in. If, again, the patient survives the 
acute peritonitis, the serous portion of the blood is slowly disposed 
of by absorption, and in time the solid clot softens down by degrees, 
and is also disposed of in the same way ; and, again, the patient may 
recover with the pelvic organs damaged by the inflammatory prod- 
ucts, which remain and behave very much as in simple pelvic peri- 
tonitis. Occasionally, however, it happens that, in place of the 
blood-clot being disposed of in this way, it breaks down, and sup- 
puration of the products of the peritonitis occurs, and death ensues 
from septicaemia. 

This, then, gives three well-defined stages in the progress of pel- 
vic haematocele : First, the stage of haemorrhage ; second, the stage 
of pelvic inflammation ; and third, the stage in which the clot is 
disposed of by absorption, or breaks down, and gives rise to sup- 
puration. 

The extent of pelvic peritonitis, and the subsequent disposal of 
the clot, or the extent of suppurative action which may take place, 
depends to some extent upon the quantity of the blood accumula- 
tion, and also upon the patient's general condition at the time, and 
the character of the blood. 

In case the patient is not in vigorous health at the time of the 
haemorrhage, and if the haemorrhage is great, the shock is more 
likely to prove fatal ; or, if that does not take place, then the extent 
and character of this inflammation, and the tendency to decomposi- 



PELVIC HJEMATOCELE. 599 

tion and suppuration, are rendered greater in case the blood is in 
any way abnormal. 

A limited quantity of normal blood in the sac of Douglas does 
not necessarily give rise to very great trouble, but we can readily 
suppose that, if blood is abnormal, as in the case of scorbutus or 
purpura, then it is more likely to be irritating, and hence the greater 
will be the inflammation and tendency to suppuration. The accom- 
panying figures, 211 and 212, illustrate the two varieties of pelvic 
hsematocele, classified according to location. 

Causation. — The causes of pelvic hgematocele are necessarily 
predisposing and exciting. There are three predisposing causes — 
certain changes in the blood-vessels of the pelvis, overdistention of 
the vessels which enfeebles their walls, and degeneration of the walls 
of the blood-vessels, which renders them more easily ruptured under 
extra pressure. Any one of these conditions of the blood-vessels may 
be produced by continued hyperaemia or, more especially, engorge- 
ment. It is well known that congestion on the venous side of the 
circulation tends to degeneration of tissues of all kinds, and the walls 
of the blood-vessels prove no exception. Hence, in cases of long- 
continued congestion of the pelvic organs from any cause, such as 
obstruction of the portal circulation, imperfect involution after par- 
turition, or in persons whose occupation compels their continued 
standing or sitting, the strength of the walls becomes impaired, and 
they are liable to rupture. On the other hand, in certain abnormal 
conditions of the blood, such as that found in purpura or scorbutus, 
there is a tendency to hsemorrhage from the small vessels under 
extra pressure. It follows, also, that the predisposition to haemor- 
rhage will be most marked during the period of ovarian activity, and 
also at the menstrual period. 

The exciting causes of pelvic hsematocele are, in a w^ord, anything 
which can produce overdistention of the blood-vessels, sudden check- 
ing of the menstrual flow, maintaining the erect position for any 
great length of time, violent exercise and overexertion, and the like, 
injuries or falls, and when the hgemorrhage comes from the Fallopian 
tubes or the uterus, it is caused by some obstruction of the cer^-ical 
canal or the Fallopian tubes. 

Symptomatology. — In the majority of patients who have this 
affection, the haemorrhage is often preceded by spnptoms indica- 
tive of some pelvic affection, but these need not necessarily be suffi- 
ciently marked to call the attention either of the patient or the phy- 
sician to them ; so it may be said that the symptoms of pelvic luvni- 
atocele are developed suddenly. The symptoms, of course, differ 



600 DISEASES OF WOMEN. 

as the disease progresses, each stage having its own characteristic 
manifestations. When the hgemorrhage occurs, there is first, severe 
pain in the pelvis, followed soon after by all the evidences of shock, 
&nch as faintness, coldness of the extremities, pallor, and cold, clammy 
perspiration, a feeling of nausea, and sometimes vomiting. If the 
temperature is taken at this time, it will be fomid to be subnormal, 
and the pulse irregular and rapid, although sometimes it is slow and 
feeble. 

In a short time to these symptoms are added well-marked pelvic 
tenesmus, including vesical and rectal tenesmus, and tympanites. 
If the hgemorrhage stops and the patient recovers from the shock, 
then inflammatory symptoms are developed. 

These constitutional and local symptoms are exactly the same as 
those observed in peritonitis, because they are diie to the peritoneal 
inflammation which usually starts up about forty-eight hours after 
reaction from the hgemorrhage. If the patient passes through the 
inflammatory stage and the blood accumulation is disposed of by 
absorption, the symptoms will then be altered to a modified pelvic 
tenesmus with occasional pain of a mild character and a general 
malnutrition, indicating some source of a mild form of septicaemia. 
On the other hand, if suppuration and breaking down of the blood- 
clot take place, the constitutional disturbances as indicated by high 
temperature, rapid pulse, and deranged nutrition, will show the sep- 
ticaemia which usually takes place under those circumstances. 

Physical Signs. — In the stage of haemorrhage there are simply 
tenderness and distention of the sac of Douglas, indicated by a mass 
which fluctuates on pressure ; the tumor is soft, smooth, and uni- 
form. 

After coagulation has taken place the mass becomes solid, but is 
still soft and yielding to the touch ; the uterus is displaced, usually 
upward and forward, so that the cervix will be found just behind 
or above the symphysis. The rectal touch will also show that the 
tumor presses upon the bowel ; abdominal palpation made after the 
tympanitic distention has subsided, will often show the mass extend- 
ing up to the superior strait and sometimes higher, and in one case 
that I saw, the blood-clot extended upward half-way to the umbilicus. 

After inflammation takes place this mass becomes surrounded 
above with the products of the inflammation which increase the 
density of the tumor and also give it a more perfect fixation. After 
the inflammation has subsided and the serous portion of the blood 
has all been absorbed and the solid clot has undergone considerable 
contraction, the mass that was originally smooth to the touch, now 



PELVIC HtEMATOOELE 601 

becomes quite irregular. As the case advances still further and the 
blood-clot breaks down and suppuration occurs, the mass maj be- 
come softer and give the impression of obscure fluctuation to the 
touch. The great difficulty which the diagnostician encounters is to 
distinguish between pelvic cellulitis, pelvic peritonitis, and hsemato- 
cele. It is also stated that pelvic hsematocele may be confounded 
with retroversion of the uterus, extra-uterine pregnancy, flbroid 
tumors, and inflammation of a small ovarian cyst which is lodged in 
the sac of Douglas, and hydro- or pyo-salpinx. There is very little 
likelihood of confounding so grave an affection as pelvic hgemato- 
cele, the clinical history of which is so marked, with any of the 
above-named conditions, except it might be an acute inflammation 
of an ovarian cyst, located in the sac of Douglas, or a Fallopian tube, 
very greatly distended with serum, pus, or blood. In either of these 
conditions — except the latter — if a diagnosis could not be made, and 
it was important at once to do so, the use of the hypodermic syringe 
used as aspirator, would settle the question detinitely. 

Treatment. — During the stage of haemorrhage this consists in 
using means to arrest the hasmorrhage, relieve the pain, and sustain 
the patient against the shock and loss of blood. To control the hsem- 
orrhage the patient should be placed on the back with the head 
and shoulders slightly elevated, in order that the blood as it accu- 
mulates in the pelvis may, by its own weight, make pressure upon 
the rupture in the vessel. Cold applications to the abdomen have 
been recommended, but usually are not well borne. Pressure made 
by applying a compress and bandage is more likely to do good ; to 
relieve the pain and sustain the patient, morphine given hypoder- 
mically is the most reliable and valuable of all remedies ; under the 
circumstances the opium acts as a stimulant as well as a relief to 
pain. In case the shock is great and liable to prove fatal, stimulants 
should be used hypodermically or by the rectum ; but in many cases 
the rectum will not retain them owing to the irritability caused by 
the hgematocele. 

It has been proposed by Dr. M. A. Fallen to open the abdomen, 
remove the blood, and stop the haemorrhage by ligating the rupt- 
ured vessels. This, theoretically, appears to be good surgery, but 
unfortunately it can never have any very wide practical application ; 
the fact is it should never be undertaken in cases where the shock 
and depression are great, because the patient would most certainly 
die under the operation, and in the less severe cases of hreniorrhage 
which are not attended by any great shock, it can usually be arrested 
by milder means. I can conceive of no condition where laparotomy 



602 DISEASES OF WOMEN". 

would be justified, except in cases where the hgemorrhage is slow 
but persistent. If one is satisfied that a haemorrhage is going on 
in the pelvic cavity, which persists in spite of all ordinary efforts 
to check it, and the patient does not suffer from shock, then lapa- 
rotomy might be undertaken ; such cases, however, are extremely 
rare, and it is difficult to diagnosticate the conditions above men- 
tioned ; hence, I think that it will be seldom, if ever, that this prac- 
tice will be followed. However, abdominal surgery has attained 
such a degree of perfection in the hands of some, at the present day, 
that it is well to keep this mode of treatment in mind as a possible 
means to be employed. 

When the inflammatory stage begins the treatment should be the 
same as that already advised in cases of pelvic peritonitis, and if the 
case progresses favorably the treatment should be continued on the 
same principle. If, however, suppuration takes place, and the pa- 
tient is placed in danger of septicaemia, the question arises how to 
relieve that condition. There are two methods, either or both of 
which may be employed if the location of the pus can be reached 
through the vagina ; aspiration may be practiced, and if that gives 
relief it may be repeated if need be ; if, however, this fails, the 
needle may be again introduced until the pus is reached, and being 
left there as a guide, a larger opening may be made, and drainage 
established ; or laparotomy and drainage may be practiced. 

Years ago, Recamier proposed to evacuate the blood-clot as soon 
as the patient had sufficiently rallied from the shock of hsemor- 
rhage ; by so doing he hoped to lessen or avert entirely the inflam- 
matory stage and the long tedious and sometimes dangerous process 
of disposing of the clot. Nelaton took up this practice, but soon 
found that it was a dangerous proceeding, inflammation and septi- 
caemia of a dangerous character being very liable to follow. It is 
possible that to-day, with the great improvements in surgery, this 
practice might give better results than in years past ; one thing I 
am sure of, and that is if the blood-clot is not disposed of in a quiet 
and favorable way but sets up a suppuration after the inflammatory 
stage is past, I should be in favor of evacuating it. This I have 
tried successfnlly in one case, a rather desperate one it was too, and 
with perfect success. I would not, however, advise operating except 
under the conditions named, because, if the evacuation of the clot is 
undertaken before it is walled in by inflammatory products, there is 
very great danger of starting up another haemorrhage which might 
not be controllable, and again there is more danger of exciting peri- 
tonitis which might become general, and end fatally. 



PELVIC HEMATOCELE. 603 



ILLUSTRATIVE CASES. 

A Case of Pelvic Haematocele uncomplicated. — A ladj of some- 
what phlegmatic temperament who was also chlorotic, had suffered 
all her life from dysmenorrha^a in a marked degree, and also scanty 
menstruation as a rule, although at times this was more free. She 
had been twice married, the last time for eight years, but had never 
been pregnant. In taking her previous history at the time I first 
saw her, I found that she had symptoms of some former pelvic dis- 
ease, probably general congestion as indicated by her dysmenorrhoea, 
leucorrhoea, and pelvic tenesmus which was aggravated on walking. 

She had lived a somewhat indolent life taking very little phys- 
ical exercise. When I saw her first I learned that on the last day of 
her menstrual flow she had been riding and walking more than 
usual, as she had some visitors whom she was entertaining by tak- 
ing them about the city. 

While getting out of her carriage she slipped and fell on the 
sidewalk ; she was taken with pain in the left side of her pelvis, and 
had to be helped into the house, and immediately went to bed ; her 
pain increased in severity, and she became very faint and nauseated ; 
I saw her about two hours after this slight accident, and found her 
suffering from partial shock ; her pulse was exceedingly feeble and 
rather rapid ; her temperature was 97^° F., and her skin was cold 
and clammy ; she was sighing frequently, and bad an expression of 
extreme anxiety and distress ; she had vomited frequently and was 
exceedingly nauseated ; she complained in a low whispering voice of 
a violent pain in the vaginal pelvis. There was considerable tympa- 
nitic distention of the abdomen with marked tenderness in the epi- 
gastric region. On digital examination I found considerable tender- 
ness, but not as much as might have been expected. 

There were signs of lluid in the sac of Douglas, but this was eas- 
ily displaced by the touch ; a diagnosis of pelvic haemorrhage was 
made, and hypodermic injections of morphine were given sufficient 
to relieve her pain ; a little brandy-and-water was also administered 
at first, but this she almost immediately rejected ; an abdominal band- 
age and compress were applied without giving any distress for two 
or three hours, but at that time she complained of its tightness, and 
it was necessary to remove it ; bottles of hot water were applied to 
the feet and limbs and also to the arms, which were kept under the 
bed-clothing. All this gave her relief from pain to some extent 
and the shock did not apparently increase, and yet she showed very 
little disposition to rally. About three hours afterward some brandy 
40 



604: DISEASES OF WOMEN". 

and beef-extract were given by enema, and repeated at intervals of 
two or three hours for some time ; the hypodermic injections of 
morphine were also repeated as often as every three hours during 
the first twelve hours. During this time she was given a grain and 
a half of morphia altogether. She then began slowly to recover 
from her shock, the hsemorrhage evidently having stopped ; her 
pulse became more rapid and a little fuller ; she breathed more nat- 
urally, and her skin became warm ; she also had less of that extreme 
faintness and depression ; still she remained nauseated although she 
was able to retain very small quantities of brandy and Seltzer-water 
and beef -extract ; the pain however was not any less except when 
controlled by the morphine. In addition to this she complained of 
marked pelvic tenesmus, especially of the bladder and rectum. She 
described this feeling as one of great fullness, weight, and pressure 
in the pelvis, which she fancied would be relieved by free evacua- 
tion of the bowels. She remained in this condition witli very little 
change ; taking opium freely and very little nourishment for about 
forty-eight hours ; at that time the physical signs showed that the 
sac of Douglas was tilled with blood which was now beginning to 
coagulate as shown by the less pelvic fluctuation on touch. Her 
temperature now rather rapidly increased, running up to 103° F., 
her pulse became more rapid and fuller ; the pain also increased, 
and nausea and vomiting again returned. She was now very tym- 
panitic and had acute tenderness on touch in the lower part of the 
abdomen ; in short, she had all the symptoms of acute pelvic peri- 
tonitis with unusual marked constitutional disturbance, owing no 
doubt to the general depressed condition due to pelvic haemorrhage. 

On the fourth day there were well-defined evidences that the 
products of the pelvic inflammation were being developed ; there 
was much greater hardening of the parts, and the mass in the sac of 
Douglas was solid or more solid as indicated by the touch. From 
this onward the physical signs were those of a pelvic peritonitis 
with an unusual accumulation in the sac of Douglas. 

The progress of the case from this time was that of a severe pel- 
vic peritonitis, and the treatment was the same as has already been 
described, hence nothing further need be said on that subject. At 
about the end of the third week the physical signs were the same, 
except that on examination a mass appeared behind the uterus which 
was somewhat irregular, small depressions and elevations being de- 
tected here and there ; the temperature and pulse had both come 
down, and yet remained above 100 ; the patient was now able to take 
a fair amount of nourishment, and her bowels were moved, but with 



PELVIC HEMATOCELE. G05 

the greatest possible difficulty ; laxatives and repeated enemata were 
given eacli time that an evacuation was obtained, and she also suf- 
fered great distress when the bowels moved. About this time she be- 
gan to show decided malnutrition ; she had lost considerable flesh, 
was pale and rather slightly bronzed looking, and her skin was dry 
and ill conditioned, giving the impression that the absorption of the 
serous portion of the blood was probably causing a mild form of 
septicaemia. From this time onward her progress was exceedingly 
slow but entirely satisfactory under tonics, nourishing diet, and mild 
counter-irritation over the hypogastric region ; she gradually re- 
gained her strength. The pain and discomfort in the pelvic region 
had become very trifling except when she tried to take exercise. 
There was no change in the physical signs except that the mass in 
the sac of Douglas had greatly diminished in size, and the uterus 
which had been pushed upward and forward close to the pubes, had 
returned in part toward its normal position. The hardening of the 
pelvic roof and the fixation of the pelvic organs remained about the 
same. 

It is needless to follow the progress of this case from daj to day ; 
suffice it to say that she made a Yerj slow recovery, that at each 
menstrual period she suffered great disturbance, and that for a long 
time was unable to walk or ride without suffering pain. Tonics, 
alteratives, and nourishing diet were given which improved her gen- 
eral condition. 

Ten months after the attack there were still signs of an excessive 
exudation in the pelvis, and also the remains of a blood-clot in the 
sac of Douglas ; still, from this time onward she was able to enjoy 
life in her own somewhat indolent way, but could not walk or ride 
without suffering more than in former years. A year and a half 
subsequently I had the opportunity of examining the pelvis, and 
found that there was still considerable fixation of the pelvic oi'gans, 
and also some hard, irregular, small masses in the sac of Douglas, 
but she did not appear to suffer very much from these, and her gen- 
eral health was fairly good. 

Pelvic Haematocele ; Evacuatioa of a Clot ; Recovery. — A French- 
woman, occupied as polisher in a watch-case factory, where her duties 
required her to occupy a standing position all day long, was suddenly 
taken ill while at work ; violent pain, followed by faintness, came 
on while she was at work. She was carried from the factory to her 
home near by, and one of my assistants was called to see her. He 
attended to her immediate wants, and saw her ngain afterward, when 
he made a digital examination, and found a fluctuating mass in the 



606 DISEASES OF WOMEN. 

sac of Douglas. On the second day lie gave me a detailed history 
of the case, and we came to the conclusion that she must have had 
a pelvic lisemorrhage ; the inflammatory action soon set in after she 
rallied from the shock which occurred, and was very severe at the 
onset of the disease, and she was again in a most dangerous condi- 
tion. Being poor, her surroundings were very unsatisfactory, and, 
by advice of the doctor, she was removed to the hospital ; she was 
admitted about ten days after the time that she was taken ilL At 
that time the pelvis appeared to contain one solid mass, so that noth- 
ing could be distinguished except a somewhat shortened vagina and 
the cervix uteri, which was curled up and firmly fixed behind the 
pubes. Her bowels were very much distended, and she suffered ex- 
tremely from pain and tenesmus ; her general condition was very 
wretched, indeed, and, as it was impossible to move the bowels, the 
question arose, What could be done to relieve the extreme pressure 
in the pelvis which threatened to destroy the organs and tissues, and 
prove fatal ? I had the extreme good fortune to secure the counsel 
of the late Prof. William Warren Greene, and we decided to evacu- 
ate the blood-clot in the hope of thereby saving the life of the pa- 
tient; accordingly, an incision was made through the posterior vag- 
inal wall into the most dependent part of the tumor, which extended 
well down into the middle line of the pelvis ; a large blood-clot 
was found, which was broken up and evacuated, and the cavity cau- 
tiously washed out. 'No haemorrhage of any amount followed, and 
she was very much relieved. I succeeded then in moving the bowels, 
which, while it distressed her at the time, subsequently gave her 
relief. The improvement lasted but a little while, however, for she 
soon developed a violent septicaemia, and it now appeared as if she 
certainly must die ; she became delirious, her pulse was extremely 
rapid and feeble, her temperature w^as 105^° F., and she was bathed 
in clammy perspiration ; her breath also had that peculiar sweetish 
odor characteristic of septicaemia or pyaemia. 

There was a free discharge of pus at this time from the wound. 

Every effort was made to sustain her by stimulants and quinine, 
given by the mouth and rectum also, and the sac was washed out 
carefully and frequently with boracic acid and water. For two days 
it seemed as if she might die at any time. 

A free and profuse diarrhoea came on, and lasted for several 
hours, and, at a consultation held by the surgical staff of the hospital, 
all agreed that she had very little chance of recovery. The treat- 
ment was thoroughly carried out, and soon the blood-poisoning began 
to diminish, the sac became smaller, the discharge less free, and, 



PELVIC HJEMATOCELE. 607 

finally, the wound closed, and she recovered from all but the prod- 
ucts of the inflammation, and these remained slightly diminished up 
to the time that she was discharged from the hospital, three months 
from the time that she was admitted. When she left the hospital 
her general health was fairly good, but there was still fixation of the 
pelvic organs, and marked induration extending across the pelvis 
behind the broad ligament and uterus. I found out afterward that 
she took care of her household after her return from the hospital, 
and about six months afterward returned to her occupation in the 
factory, where she remained at work when last heard of, two years 
from the time she was first taken sick. 

A Case of Subperitoneal Hsematocele ; Recovery. — A lady, whose 
age does not appear in my notes, was married, and had three chil- 
dren, and was under my care for endometritis, associated with a good 
deal of general congestion of the pelvic organs. She was progressing 
fairly well until one day, when she went to New York shopping ; 
she walked and stood considerably, and on her way home in the 
afternoon, after crossing the ferry, decided to walk to her house, a 
distance of about three quarters of a mile ; she did this because she 
was somewhat proud of her improvement under treatment. When 
about haK through her short journey, she was seized with pain in the 
left side of the pelvis, which became so severe that she was obliged 
to sit down on the door-steps of a house near by, and, after resting 
for a short time, she managed to get home, went to bed, and applied 
a mustard-paste over the painful side ; the next day or two she re- 
mained in bed, the pain gradually diminishing, though it did not 
wholly disappear. Four days afterward she rode to my office, and, 
on digital examination, I found a round, rather flat tumor in the left 
broad ligament, low down ; it was somewhat solid to the touch, and 
tender. Being very desirous of knowing what this peculiar and sud- 
denly developed tumor could be, I introduced a small aspirating- 
needle, and drew off a few drops of blood-serum and a few very 
minute shreds of blood-clot, but failed to find anything more, al- 
though I made a strong effort to do so. I then withdrew the needle, 
and found that it contained a long shred of blood-clot ; this satisfied 
me that she had had a hgemorrhage into the cellular tissue of the 
broad ligament. I watched her wdth care and anxiety, but there was 
no inflammatory action established at that point, and the tumor 
slowly and completely disappeared. 

Subperitoneal Pelvic Haematocele discharging into the Pertioneal 
Cavity, and ending fatally.— The following case is taken from the 
work of Thomas on " Diseases of Women " : " In a case which I saw 



608 DISEASES OE WOMEK 

with Dr. Emmet, we were unable to make a diagnosis of a tumor 
wliicli lay obliquely anterior to the uterus„ In twenty-four hours 
the patient fell into a state of collapse, and, as we saw her thus, the 
nature of the tumor, which we were doubtful about on the previous 
day, became evident. Upon a post-mortem examination, an ante- 
uterine hasmatocele as large as a goose's egg was found under the 
peritonaeum, through w^hich it had broken, discharged a portion of 
its contents into the peritonaeum, and caused collapse and death. 
This is the only ante-uterine, but not the only subperitoneal, haema- 
tocele with which I have met." 

For an illustration of subperitoneal pelvic haematocele giving 
rise to cellulitis and suppuration, the reader is referred to a case 
given under the head of " Pelvic Cellulitis." 



DISEASES OF THE URI^AEY OEGANS. 



CHAPTER XXXI Y. 

ANATOlVrr AND DEVELOPMENT OF THE BLADDEK AND URETHEA. 

This portion of the present work is undertaken with the full 
assurance that the medical profession is in need of a systematic and. 
practical treatise on the diseases which affect the urinary organs of 
the female sex, and that such a treatise should be included in every 
work on gynecology which lays claim to being complete. Those 
engaged in active practice often encounter cases of cystic disease 
among their female patients, many of which are exceedingly trouble- 
some if not altogether impossible to manage. There is, moreover, 
but little in English literature, at least, to aid them when thus per- 
plexed with the difficulties of diagnosis and treatment. 

In considering this important subject after the plan which I have 
adopted, much will be purposely omitted, which, though interesting, 
is not absolutely necessary to a clear understanding of its essential 
principles. The conflicting views of various authors regarding un- 
settled questions will, when possible, be entirely disregarded in order 
to make room for the more practical points which the physician is 
expected to carry with him in his daily practice. In short, it will 
be my purpose to supply, so far as I may be able, the deflciency in 
this branch of medical literature, the existence of which a busy life 
in private practice and in teaching medical students and post-gradu- 
ates has demonstrated. 

To proceed systematically, I will first take up the form and struct- 
ure of the bladder and urethra, and the relations which they bear to 
other organs and tissues in the female, and then pass on to the con- 
sideration of their development. 

Anatomy of the Bladder. — The bladder is a musculo-membranous 
sac, situated in the anterior part of the true pelvis. Its form varies 
with the age of the individual and the degree to which it is dis- 



610 



DISEASES OF WOMEX. 



tended. In childhood, the vertical diameter is the longest ; in mid- 
dle life, the ti-ansverse ; in old age, from the sagging of the infe- 
rior fundus and gradual atrophy of the pelvic organs, the vertical 
again becomes the longest diameter. When empty, its walls are 
closely coaptated, and it lies behind the pubes. Between the pubes 
and the bladder is a space containing loose fat. TThen moderately 
filled, it rises slightly above the pubes, and assumes a somewhat ovoid 
shape^ which is much more marked during distention. In the fe- 
male the bladder has a shorter auterc-posterior and a greater lateral 
diameter than in the male. 

The bladder in the female is, for accuracy and convenience of 
description, divided into corpus (body), fun- 
dus (base), and cervix (neck) (see Fig. 213). 

The corpus is all that portion of the oi-gan 
lying above an imaginary plane, passing 
thi'ough the vesical openings of the ureters 
and the center of the symphysis pubis. That 
part lying below this plane is the fundus or 
base, and is variously divided. Tlie portion 
which lies between the vesical openings of 
the ureters behind, and the vesical oritice of 
the urethra in front (Fig. 21J:), is known as 
the trigone, or vesical ti-iangle. That portion 
Fig. 213.— Diagram of the of the base Iviug just behind the ureteric 

bladder to show corpus . . -, " ^i i x ^ 'T^i • • 

and fundus. opcmugs IS Kuown as the bas lond. I ins is 

usually but a slight depression in early and 
middle life, but in disease and advanced age it often becomes a 
deep pouch or sac. This is more often the case in the male than 
in the female. The cervix or neck of the bladder is that funnel- 
shaped space at the apex of the trigone, where the bladder and ure- 
thi'a merge into each other. 

The bladder has three coats — two complete and one partial or 
incomplete. From without inward these are the serous i incomplete), 
the muscular, and the mucous. The serous investment of the blad- 
der, like that of all the abdominal and pelvic organs, consists of 
peritonaemn, of which I will s}~)eak more fully when I come to con- 
sider the ligaments and topographical relations of this organ. 

The middle or muscular coat has a peculiarly efficient fiber ar- 
rangement. Its layers have been divided into two — external and 
internal — but so frequent and so intimate are their interlacements 
that, though when minutely considered they are two. practically they 
act and appear as one. The main direction of the outer fibers is 




ANATOMY OF THE BLADDER. 611 

longitudinal ; of the inner, circular. There is also a thin stratum 
of muscular liber lying just under the mucous membrane, and con- 
tinuous with the longitudinal fibers of the urethra. The main fibers 
are of the unstriped or involuntary hind, and take their origin chiefly 
from the neck of the bladder. 

According to some authors, the sphincter vesicse is formed by a 
strong band of muscular fibers, varying from one eighth to half an 
inch in thickness. By others, and these are perliaps the best au- 
thorities, it is claimed that there is no true anatomical sphincter of 
the bladder. The function of the sphincter vesicae is said to be per- 
formed by the closing together of the longitudinal folds of the tis- 
sues at the junction of the bladder and urethra, or by the transverse 
semicircular folds that close over each other. 

At the base of the bladder two little muscular slips arise from 
the portion usually designated as the sphincter vesicae, and find in- 
sertion about the vesical openings of the ureters. These muscular 
fasciculi are but imperfectly developed in the female, and probably 
have little if any specific action. 

The lining or mucous coat of the bladder is like that of the ure- 
ters and urethra. It consists of a basement membrane, supporting 
two or more layers of epithelium, in some parts squamous, in others 
cylindrical, the whole lying upon an elastic, cellulo-vascular bed that 
is fitted into the meshes of the reticulated muscular coat beneath. 

This mucous membrane is nowhere attached closely to the sub- 
jacent muscular layer, save at the trigone, the neck, and about the 
orifices of the ureters. Owing to the general looseness of attach- 
ment when the bladder is partially or wholly contracted, the mucous 
membrane is thrown into rough, uneven folds everywhere, save at 
the points of close attachment already mentioned. 

In the trigonal space the membrane is thinner, more closely ad- 
herent, and the surface epithelium is usually of the medium-sized, 
squamous variety. The nerve-supply to this small space is very 
rich, and, in consequence, it is the most sensitive part of the blad- 
der. 

Although Savage denies the presence of glands or papillge in the 
raucous membrane of the bladder, Holden and many others main- 
tain (and correctly, I think) that the membrane is studded with 
numerous little glands and follicles, whose function is to supply 
mucus to the internal surface of the ore^an. Thev are most nuuier- 
ous at and about the vesical neck. 

The trigone in the female is a smaller space, and has less dis- 
tinctly marked boundaries than in the male. That little elevation 



612 



DISEASES OF WOME!?^. 



,^ 



.4 



of mucous membrane lying at tlie very apex of the trigonal space, 
and known as tlie nvnla, is also but little developed in the fe- 
male. 

Kunuing between the vesical orifices of the ureters, Jurie claims 
to have found what he calls the inter-uTeteriG ligament^ in the ends 
of which he asserts that the m-eteric orifices ai-e imbedded. To its 
action he attributes the power that the bladder has of preventing 
regiii'gitation into the ureters. I will speak more fully on this point 
presently. 

formally, the bladder has three openings, one for each ureter, 
and the urethral orifice. The openings of the ureters lie on each 
side of the median line at the base of the bladder, about one inch 
and a half behind the vesical opening of the urethra, and about two 
inches apart. The ureters pierce the bladder- wall obliquely, and their 
openings are so minute as to be hardly visible to the naked eye. 
Their points of entrance are marked by a slight puckering in the 

mucous membrane. 
The third opening is 
the ostium urethrse 
internum, which is a 
diagonal slit at the 
juncture of the vesi- 
cal neck and urethra. 
According to Rii- 
tenberg, the color of 
the vesical mucous 
membrane in the liv- 
ing subject before 
dilatation is a dull, 
grayish red ; but, as 
dilatation proceeds, 
and the irregular 
folds are straightened 
out, it becomes grad- 
ually a brighter red, 
and, when complete 
distention is accom- 
phshed, the minute 
arteries can be seen 
forming a beautiful interlacing network on the bands of the muscu- 
lar reticulse. AYhenever it has been my good fortune to see this 
membrane in the living subject, it has appeared to me as being of a 



^ 2 




"^^glMBM 



^ 



Fig. 



214. — Base and neck of the bladder (Savage), a, sym- 
physis pubis. 1, 1, Ureters. 1', Ureteric openings. 
2, 3, Uterine artery and veins. 4, Outline of cervix 
uteri.' 5, Vesical neck. 6, Arcus tendineus and vesico- 
pubic muscles. 7, 7, Pubo-coccygeus muscles. 



ANATOMY OF TFIE BLADDER. 613 

grajish-pinlv color, not unlike that of the mucous membrane of the 
cervix uteri when anaemic. 

The vascular supply of the bladder is very free, being derived 
from the superior, middle, and inferior vesical arteries, and branches 
from the uterine artery. They all arise from the anterior trunks of 
the internal iliac arteries. The anastomoses of the arterial twigs are 
numerous and free. The veins are also numerous and large, form- 
ing by interlacement and connection thick, tortuous plexuses about 
the base, sides, and neck of the bladder, and finally terminate in the 
internal iliac veins. This plexus about the neck of the bladder com- 
municates freely with that of the labia minora, uterus, and rectum. 
These venous plexuses are the chief elements in the so-called '' haem- 
orrhoids of the bladder." 

In their tortuous course these veins are accompanied by lym- 
phatics that seem to have their origin in the submucous cellular 
tissue of the bladder. They enter the glands situated about 
the internal iliac artery, and from there go to the lumbar 
glands. 

The nerves of the bladder are of two kinds — spinal and sympa- 
thetic. The spinal nerves are branches, usually from the fourth, 
sometimes from the third, and rarely from the second sacral nerve. 
They terminate chiefly in and about the neck and base of the blad- 
der. The sympathetic nerves have their origin from the hypogastric 
plexus, which lies in front of and on the last lumbar and first sacral 
vertebrae. It is formed by a mazy interlacement of numerous gan- 
glionic fibers, and branches from the spinal nerves, especially the 
second sacral. Ganglia are common, more particularly at the point 
of junction of the spinal and sympathetic nerves. This plexus sends 
branches to all parts of the bladder, and to the vagina, uterus, and 
rectum. This common nerve-supply to the various pelvic organs 
must be borne distinctly in mind in order that the functional de- 
rangements and neuroses of the bladder, hereafter to be described, 
may be thoroughly understood. 

Anatomy of the Urethra. — The female urethra is a musculo-mem- 
branous canal, from one to two inches in length, the average being 
about one inch and three eighths. Its diameter is greater than that 
of the male, being about one fourth of an inch. 

It lies in the median line, just under the pubic arch, and is held 
in position by the median pubo- vesical ligament. In the erect posi- 
tion it has a direction upward and backward, and at all times, when 
normal, its axis closely corresponds to that of the pelvic outlet. It 
terminates anteriorly at the base of the vestibule by an opening 



614 



DISEASES OF WOMEN, 



■I 



known as the meatus urinariiis, and posteriorly at the neck of the 
bladder. 

It has a cellular, a double muscular, and a mucous coat. Accord- 
ing to Robin and Cadiat. its mucous membrane is richer in elastic 
tissue than any other in the body. The epithehal covering of the 
anterior or lowest portion is of the pavement variety, and closely 
resembles that of the vagina, except that it is not so large. Tigs. 
217 and 218 show the difference between the 
', two. Posteriorly and superiorly it is like that 

^ • ' of the bladder — columnar and squamous. 

I Scattered throughout are little papillae, con- 
I taining blood-vessels, and near the meatus 
I there ai-e numerous lacunae surrounded by 
- villous tufts. There is also a number of small 

^ mucous glands, that in old people often con- 
tain black particles, like the prostatic concre- 
tions of the male. 

Upon each side, near the floor of the fe- 
male urethra, there are two tubules lai'ge 
enough to admit a No. 1 probe^of the French 
scale. They extend from the meatus uiinari- 
ns upward, from three eighths to three quar- 
ters of an inch. Fio:. 215 is a drawino^ from 
a section of the urethra, laid open by division 
of its posterior or vaginal wall. The tubules, 
having been distended by probes passed into them, are plainly seen. 
Fig. 216 shows the same thing from the opposite side, the ure- 
thra having been laid open by section of its ante- 
rior wall. The space between the tubules is the 
floor of the urethra. From these it will be ob- 
served that the tubules run parallel with the long 
axis of the m'ethra. 

They are located beneath the mucous mem- 
brane in the muscular walls of the urethra. 
This is represented by Fig. 217, which is a draw- 
ing taken from a transverse section of the ure- 
thra, about a quarter of an inch from the meatus. 
The mouths of these tubules are found upon 
the free surface of the mucous membrane of the 
urethra, within the labia of the meatus urinarius. Fig. 216.— Urethra laid 
The location of the openings is subject to slight open with probes in 

. ^Vu jv ^ M^ Skene's glands (an. 

variation, according to the condition and lorm terior wall divided). 



Fig. 215. — Urethra laid 
open with probes dis- 
tending the glands ( pos- 
terior wall divided). 



J 



*?. . . ^ 



n'- 




ANATOMY OF THE URETHRA. 



615 



of the meatus. In some subjects, especially tlie jouDg and very- 
aged, and in those in whom the meatus is small, and does not pro- 
ject above the plane of the ves- 
tibule, the oritices are found 
about an eighth of an inch with- 
in the outer border of the mea- 
tus. When the mucous mem- 
brane of the urethra is thickened 
and relaxed, so as to become 
slightly prolapsed, or when the 
meatus is everted, conditions not 
uncommon in those who have 
borne children, the openings are 
exposed to view upon each side 
of the entrance to the urethra. 
What is here described is rep- 
resented in Fig. 219. The labia 
of the meatus have been slight- 
ly everted to bring the orifices 
into view. 

The upper ends of the tu- 
bules terminate in a number of 
divisions, which branch off into 
the muscular walls of the ure- 
thra. By injecting one of the 
tubules with mercury, and then dividing it, the openings of the 
branches can be easily seen. 

This description of the anatomy of these glands is taken from 
dissections and microscopical examinations made by Drs. B. F. West- 
brook and J. M. Van Cott, Jr. I have called them glands because 
they differ in size and structure from the simple follicles found in 
abundance in the mucous membrane. 

When I first discovered these glands I presumed that they were 
mucous follicles that were accidentally of unusual size in the subject 
examined, but, having investigated more than one hundred of them 
in as many different subjects, and finding tbem constantly present, 
and so uniform in size and location, I became satisfied that they were 
worthy of a separate place in descriptive anatomy. The dissections 
made by Dr. Westbrook, and the pathological lesions to which these 
structures are subject, confirm this belief. 

So far as I know, the anatomy of these glands has not been de- 
scribed, nor have the diseases to which they are subject been referred 




Fig. 217. 



Transverse section of urethra with 
gland on either side. 



616 



DISEASES OF IVOMEK 



to by pathologists. At least this much may be said, that the stand- 
ard text-books on anatomy and gynecology in English, German, and 
French contain no reference to them. 

It is easy to understand why these insignificant glands should 




Fig. 218. — Longitudinal section of urethral glands. 

have been overlooked by anatomists, or, if noticed at all, classed with 
other mucous folhcles. It is only when their pathology is under- 
stood that their real importance becomes apparent. 

I know nothing about their physiology. They serve some pur- 
pose in the economy, no doubt, but what is their function is a ques- 
tion to be answered in the future. This will doubtless be attended 
to at an early date, as the subject is worthy of investigation. The 
pathology of these glands, so far as has been investigated up to this 
time, is of great practical interest, and there remains, no doubt, much 
still to be studied. Clinical observation has already shown that 
they are subject to inflammation of various degrees of intensity 
and duration. 

The meatus urinarius in the female differs from that of the male 
in being a puckered and somewhat prominent, rather than a slit-like 



ANATOMY OF THE URETHRA. 



617 







#' 



Fig. 



219. — The meatus everted, 
showing the mouths of the 
glands. (From a prepara- 
tion preserved in alcohol.) 



and depressed opening. The mucous membrane of the urethra is 
thrown into longitudinal folds throughout, save when opened and 
unwrinkled during micturition or by arti- 
ficial dilatation. When at rest it is a 
closed canal. 

Beneath the mucous membrane there 
is a thick fibro-elastic network into which 
the mucous glands dip. These are lined 
with cylindrical epi thel ium an d surrounded 

by a network of veins. This submucous / "^\ 

areolar tissue has direct vascular connec- 
tion with the muscular layer that sur- 
rounds it by means of cavernous venous si- 
nuses, partly in the muscle and partly in 
the elastic connective tissue. Thus there 
is an arrangement almost exactly like that 
of the corpus cavernosum penis in the 
male. The venous plexus of the urethra 
is situated chiefly at the sides, in w^hat is 
known as the urethro-pubic space. 

The muscular layer is double, the outer 
portion being composed of both circular and spiral libers mixed, and 
the inner of longitudinal fibers only, and these two layers are so 
closely bound together by the cavernous venous sinuses as to be in 
reality but one. Dr. Ufileinan claims to have found an additional 
external layer, the fibers of which are voluntary. He divides this 
layer into two — an external and an internal — the former longitud- 
inal, the latter transverse. These make what he calls the outer or 
voluntary sphincter of the bladder. From the vesical neck to a 
point about half-way down it wholly invests the urethra, forming 
only a ]3artial investment from that point to the meatus. 

Luschka claims to have found a sphincter of the urethra and 
vagina. He describes it as being smooth and circular, from one 
sixth to one third of an inch broad, lying directly behind the vesti- 
bule, and girdling both the vagina and urethra. Its function, he 
says, is to close the urethra by pressing it against the urethro-vag-i- 
nal septum. Being closely adjacent to the cavernous venous tissue 
of the urethra, it locks its fibers posteriorly with those of the mus- 
culus trans versus profundus. 

In the female as in the male, the urethra pierces the tnaiigiilar 
subpubic ligament, two layers of which extend ai'ound it ; one back- 
ward and the other forward. 



618 DISEASES OF WOMEN. 

There is great diversity of opinion as to the nature of the vesi 
cal opening of the urethra in the female. According to Winckel 
and Simon it is a diagonal slit, the mucous membrane of which is 
longitudinally and superficially corrugated. According to Savage, 
it is a triangular opening ; and according to Holden and others, a 
funnel-shaped opening. It of course varies somewhat with age, size 
of urethra, vesical contraction, or quiescence, and in the living and 
dead subject ; and hence the diverse opinions of the various ob- 
servers. 

Anatomical Relations of the Bladder and Urethra. — Having dis- 
cussed the anatomy of the bladder and urethra, it remains to exam- 
ine the topographical relations of these organs. This is very neces- 
sary to a proper understanding of the influence of other organs in 
causing diseases and displacements of the bladder and urethra. 

The bladder of the female lies lower in the pelvis than that of 
the male, between the pubes anteriorly, the uterus posteriorly, the 
vagina and uterine cervix, inferiorly, and the small intestines superi- 
orly. The organ when empty lies behind the symphysis pubis, its 
highest point slightly overtopping it. In this position it occupies 
but little space. When partially or wholly Hlled it rises above the 
pubes to a varying extent. In doing this it alters but slightly the 
position of the other pelvic viscera, although relatively its position 
is somewhat changed. 

Anteriorly the bladder is separated from the i^osterior face of 
the pubic symphysis by intervening cellular tissue. Inferiorly it 
forms a close attachment to the anterior vaginal wall by means of a 
dense cellular cushion which increases in thickness from before back- 
ward. The bladder rests upon this vesico- vaginal septum as far up 
as the point where the body and neck of the uterus join each other. 
Posteriorly and somewhat superiorly to the bladder lies the uterus, 
and superiorly and postero-laterally are the ovaries and broad Kga- 
ments. 

The close attachment of the vesical neck to the arch of the pubes, 
by the pubic ligament anteriorly and the vagina inferiorly, makes a 
kind of wedge that gives but little surface for bagging downward 
if the vagina holds its proper position. Though imperfectly, still to 
a certain extent, this arrangement resembles the perinseum in the 
male. Superiorly, the organ is held in position by a number of 
ligaments ; fi.ve false and five true. The false ligaments (one supe- 
rior, two lateral, and two posterior), are formed of peritonaeum. 
This membrane is reflected from the inner face of the anterior ab- 
dominal wall to the bladder investing it superiorly, laterally, and, to 



EELATIONS OF THE BLADDER AND UKETHRA. 619 

a certain extent, posteriorly. It joins tlie organ in front, dipping 
down just above the pubic summit to the superior vesical surface, 
and passes as far backward as the point of contact between the vesi- 
cal base and uterus, which is at the junction of the uterine body and 
cervix. Although this peritoneal covering of the bladder is hrmlj 
adherent, it never leaves its uterine or other attachments, however 
much the bladder may be distended and rise above the brim of the 
pelvis. 

That portion of the bladder lying behind the pubes, that resting 
on the vagina and uterine neck, and a small posterior and lateral 
portion have no serous investment. 

The true ligaments are also five in number — two anterior or 
vesico-pubic, two lateral, and the superior or urachus cord. 

Laterally, the round ligaments of the nterus pass over the blad- 
der-wall, and just below and posteriorly the ureters enter that 
organ. 

These ducts, the excretory ducts of the kidneys, are usually de- 
scribed as passing downward, forward, and inward, after entering 
the cavity of the pelvis, to the base of the bladder, and after passing 
for an inch between the muscular coats of that organ opening into 
it by constricted orifices. In their course they pass along the sides 
of the cervix uteri and upper part of the vagina, and at their points 
of entrance into the bladder are from one half to three quarters of an 
inch in front of the cervix uteri. It is yerj important that the re- 
lation of the ureters to the bladder should be borne in mind, espe- 
cially in the operation of gastro-elytrotomy. Garrigues, who has in- 
vestigated this point, says : " The ureter does not lie in the broad liga- 
ments, it does not keep the same direction on reaching the wall of 
the bladder, and it does not lie close up to the wall of the cervix, as 
taught by anatomical authorities. After having crossed the iliac 
vessels the ureters diverge, running down^vard, backw^ard, and a lit- 
tle outward on the wall of the pelvis, behind the broad ligaments to 
a point near the spina ischii. Then they lead downward, forward, 
and considerably inward so as to converge toward the bladder. They 
pass beneath the base of the broad ligament, lying in the abundant 
cellular tissue found in this locality. They cross the cervix at some 
distance from behind, at an acute angle, so as to come in front of 
and below it. They lie outside and above the anterior part of the 
side wall of the vagina on a spot as large as the tip of the finger. 
On reaching the wall of the bladder they turn rather sharply inward 
and go downward until they open with a small slit into the inte- 
rior of the bladder at the outer angle of the trigonuni vesica?. But 
41 



620 



EELATIONS OF THE BLADDER AND URETHRA. 




on dissecting the bladder from the uterus and vagina their substance 
is seen to continue as a solid ridge between the two apertures, and 
forming the base of the trigone (Jurie's inter-ureteric ligament.) " 

The illustration of Grar- 
rigues makes this descrip- 
tion very clear (Fig. 220.) 
Just in front of the 
small lateral space lacking 
serous investment the ob- 
literated umbilical arteries 
pass upward and forward 
to the summit of the blad- 
der reflecting the perito- 
nseum, and thus forming 
a double pouch on either 
side. 

The relations of the 
urethra are as follows : it 
lies just under the pubic 
symphysis, and, piercing 
the deep perineal fascia, 
extends from the vesical 
neck, at the ostium ure- 
thrse internum, to the meatus urinarius or ostium urethrse externum, 
situate at the base of the triangular space known as the vestibule. 
Its anterior three fourths are imbedded in the vaginal wall. The 
meatus urinarius lies about four fifths of an inch below the clitoris, 
in the vaginal margin of the vestibule. The vesical end of the 
urethra is about the same distance below the lower surface of the 
pubic symphysis. Its course is upward and backward forming a 
very slight curve. 

Development of the Bladder and Urethra. — With this brief sketch 
of the structure of the bladder and urethra their development may 
be next considered. It would be very interesting, from a scientific 
point of view, to examine the process by which the bladder and 
urethra are formed in the embryo ; but it would, I think, be rather 
tedious to take up the subject in all its minutiae. A few of the 
more important points in the process of development must be un- 
derstood, however, in order to comprehend the malformations which 
are occasionally met with. Most, or at least many, of the malfor- 
mations of the urinary apparatus, like those of other organs are due 
to arrest of development at various stages of that process. A clear 



220. — The relations of the ureters (Garrigues). 
u, uterus ; b, bladder ; wr, ureter ; ?{, urethra ; 
V, vagina ; f, Fallopian tube ; o, ovary ; 6, broad 
ligament ; y, round ligament. 



DEVELOPMENT OF THE BLADDER AND URETHRA. 621 

conception of the normal, therefore, ^\dll aid in better imderstancling 
the abnormal. 

The nrinarj organs are developed in separate portions or sec- 
tions having distinct points of origin, and by the union and fusion 
of these parts the entire apparatus is completed. 

The bladder is formed from a portion of the allantois. When 
the abdominal plates of the embryo close around that portion of the 
allantois that forms the umbilical cord, they also shut in a portion 
which forms the urinary bladder. There remains, for a time, a di- 
rect communication between that portion of the allantois from which 
the bladder is formed and that which makes the cord, which takes 
the name of the urachus. The canal or duct in the urachus is usu- 
ally obliterated before or soon after birth, so that all that remains of 
it is an impervious cord known as the superior vesical ligament. It 
will thus be seen that the bladder is developed from the allantois, 
which may be called one center of development for the urinary ap- 
paratus. 

The centers of development for the ureters are the same as those 
for the kidneys. Indeed, the ureters are processes that are developed 
from the kidneys, and extend downward until they unite with the 
bladder, and finally open into it. 

While the bladder and ureters are being thus formed, the lower 
portion of the alimentary canal — that which forms the rectum — be- 
comes separated from the section of the allantois that forms the 
bladder. Into this space, between the rectum and bladder, Miiller's 
ducts descend, and, uniting, form the vagina (see Figs. 53-57). 

Posterior to Miiller's ducts and anterior to the rectum, a mass of 
tissue is developed which helps to form the recto- vaginal wall above 
and the peringeum below. 

Anteriorly Miiller's ducts unite with the lower portion of the 
bladder, and aid in the formation of the urethra, or, at least, the up- 
per portion of its posterior wall. 

The lower or external portions of the genito-urinary organs are 
formed from an ovoid eminence which appears in the median line 
of the lower anterior part of the trunk of the embryo. At the lower 
part of this eminence there appears a fissure, which, incurvating and 
uniting with the lower portion of Miiller's ducts (vagina) forms the 
terminal portion of the urethra and the introitus vagiuii?. From this 
same center of development the labia majora, the labia minora, and 
the vestibule are formed. 



CHAPTEE XXXV. 

MALFOEMATIOXS OF THE BLADDER AXD URETHRA. 

Malformations of the Urethra. — Malfonnation?, as has already been 
said, are usually the result of aiTested development. Various fail- 
ures in the processes necessary to form the complete urethra result 
in a number of malformations. The most important of these may 
be classified as follows : 

1. Defectus urethras totalis. 

2. Defectus urethrae externus. 

3. Defectus urethrse internus. 

4. Atresia urethra?. 

In the first form (defectus urethrse totalis) there is, as the term 
implies, entire absence of the urethra. It is said to be due chiefly 
to an arrest in the development of the vagina at a point where it 
should form the main portion of the posterior wall of the urethra. 
It is very probable that there is also an arrest of development of 
the clitoral process. 

Coexisting with this malformation other developmental defects 
are generally but not invai'iably found, for it has been known to exist 
with an otherwise perfect genito-urinary apparatus. Petit tells of the 
case of a child, four years old, who had neither urethra, clitoris, nor 
nymphae, but had a comparatively wide vagina. Langenbeck men- 
tions the case of a girl, nineteen years of age, in whom the bladder 
and vagina formed a common canal. She was incontinent up to the 
age mentioned, and is reported to have gained control of the bladder 
afterward. 

The second deformity (defectus urethrae externus) is due to the 
absence of the lower and anterior portion of the urethra. It has 
been called ''hypospadias in the female." One of the most marked 
cases has been recorded by Yon Mosengeil. The subject was a girl 
eight years old. The opening in the urethra was situated below a 
large clitoris, having a very full prepuce. It was much higher than 



MALFORMATIONS OF THE BLADDER AND URETHRA. 623 

the normal situation of the meatus urinarins. There was a groove 
running from the lower border of the vestibule up to the opening of 
the urethra, and it appeared to be formed from the anterior wall of 
the urethra. The upper portion of the urethra held its normal rela- 
tions to the bladder and vagina, but was only half an inch in length. 
The bladder, in comparison with the other organs, was larger, and 
had a number of sacculse. It will be observed that in this case 
the upper portion of the urethra was complete, and that there were 
present in the lower portion of the canal an anterior and two rudi- 
mentary lateral walls, the posterior wall alone being absent. 

There is another form of defectus ure three externus or hypos- 
padias, in which the lower part of the canal is entirely wanting. In 
such cases there is but one opening between the clitoris and peri- 
nseum, and but one canal, this dividing into vagina and urethra at 
some distance from the outer opening. An interesting example of 
this w^as observed by Willigk, in a woman, who died at the age of 
forty-six. The uro-genital canal, at its opening, was about the size 
of a catheter, and ran in a curved direction under the pubes. About 
an inch and a half from its outer opening it divided into two pass- 
ages, one anteriorly, V^ long — the urethra, and one posteriorly, 2'' 
to 10'^ long — the vagina. 

The third deformity (defectus urethrse internus) is that in which 
the internal or upper portion of the urethra is wanting, and is a 
comparatively rare affection. The only cases, so far as I know, are 
given by Oberteufer and Duparcque. In Oberteufer's ease, as I 
understand it, the lady was forty-two years of age, and all her life 
had passed water from the umbilicus. Her vagina was normal, and 
so were the external genital organs. The upper or internal portion 
of the urethra alone was wanting. Duparcque's case was one in 
which the urethra was pervious as far as the bladder, but was there 
closed. This case, however, appears to me more properly to come 
under the head of atresia urethrae. 

The fourth class (atresia urethrse) is a comparatively common 
affection. There are two forms of congenital atresia mentioned by 
authors. The first is produced by imperfect development of the 
vaginal process, or of both the clitoral and vaginal segments. Du- 
parcque's case was of this kind, the urethra being open up to the 
bladder and there closed. It was a form of defectus ui-ethra^ in- 
ternus with atresia at the upper end of the canal. In this ease the 
bladder and ureters were greatly distended. 

The other form of atresia is found when the clitoral and vagi- 
nal processes are both defective. In such cases there is no trace of 



624: DISEASES OF WOMEN. 

a uretlira, except an imperfect vaginal wall which extends obliquely 
downward and closes the bladder. E. Rose relates a case of this 
kind in which the bladder, kidneys, and abdomen were filled with 
water. The urethral malformation was not the only one in tliis case, 
the vagina and uterus suffered from an arrest of development and 
were both double or rudimentary. 

Before leaving this interesting subject I will mention another 
rare malformation. It is an obstructive anomaly, and consists in a 
double condition of the urethra. The only case, so far as I know, 
which has been described with any accuracy, is that of Furst. He 
observed in a preparation taken from the body of a young virgin the 
following pecuharities : In looking at the anterior bladder-wall at 
the first glance only one urethral orifice was to be seen, but one 
tenth of an inch forward toward the meatus the single urethra was 
seen to bifurcate ; a fine septum, nearly straight, divided it from 
right to left into an anterior and posterior half ; these continued 
with an ever enlarging and diverging septum until they opened into 
the vagina about one tenth of an inch apart. In this way they 
twisted, so that the anterior or superior one opened toward the right, 
while the posterior (the one in the region of the bladder) opened 
into the vagina on the left. The left urethra opened with a caliber 
of one fifth of an inch into the median line of the vagina. The right 
opened on the right of the median line, having a caliber of only one 
tenth of an inch. The length of the w^hole urethra was one inch. 

It is of very rare occurrence that the double condition of the 
allantois persists in this manner, and, considering all tlie changes 
that the sinus uro-genitalis has to undergo, it seems strange that 
blending did not take place. It is also interesting from the fact 
that the allantoic openings into the cloaca can only take place by a 
very rapid and early interruption of development. The uterus and 
vagina, in this case, were perfectly normal. 

Symptomatology of Malformation of the Urethra. — The symptoms 
that arise from malformation of the urethra are incontinence in the 
one class of cases, and retention of urine in the other. When the 
urethra is deficient in part and the bladder perforate, urine con- 
stantly escapes ; and from the wetting, the excoriation, and the odor, 
the unfortunate subject is kept in continual misery. 

In cases where there is an abnormal contraction of the vagina 
the urine can be retained, partially at least. This is supposed to be 
effected by the small size of the genito-urinary sinus, and, possibly, 
a voluntary contraction of the sphincter vaginae muscle which may 
act as a sort of sphincter and aid in the retention of urine. 



MALFORMATIONS OF THE BLADDER AND URETHRA. 625 

Atresia of the urethra and the consequent retention of the urine 
cause hydrops of the bladder, ureters, and kidneys, and also ascites, 
as has already been mentioned. Distention of these organs occurs 
in idero^ and such malformed children are usually born dead, or die 
£0on after birth. So great is this distention of the bladder and ab- 
domen in some cases that delivery is difficult or impossible until 
the fluid is evacuated by puncture. I remember seeing one such 
case. The head was delivered, but there was great difficulty in de- 
livering the body. The abdomen was enormously enlarged by the 
overdistention of the urinary organs. The child was very feeble, 
and after moaning for a few hours, died. J^o effort to relieve the 
bladder was made because a diagnosis was not reached until the lit- 
tle one was dead. 

This malformation usually leads to fatal results, and our knowl- 
edge avails us little save in accounting correctlj^ for the cause of 
death. The only natural way that the evil effects of this malforma- 
tion can be obviated is by the occurrence of another developmental 
anomaly, viz., fistula of the urachus, the urine then escaping from 
the umbilicus. Atresia is an undoubted factor in the production of 
urachal fistula, I shall speak more fully of this when I come to 
consider vesical malformations. 

When defectus urethrse externus occurs in patients whose tiro- 
genitals are otherwise normal, the function of the bladder and re- 
productive organs may all be performed easily and uninterruptedly. 
Coitus has been possible, and conception has been known to occur 
in such cases. 

Diagnosis. — In making a diagnosis of these deformities reliance 
can not be placed on the symptoms alone. A physical examination 
of the parts is necessary. The general relative appearance of the 
external organs must be observed, and if the vagina is large enough 
to admit the speculum it should be used, and if there is any malfor- 
mation internally it can easily be discovered and its exact location 
and nature ascertained. There is usually very little trouble with 
such cases, but where the entrance to the vagina is so narrow that 
it will not admit a sound or speculum, the diagnostic skill of the 
physician will be severely taxed. Such cases resemble imperforate 
hymen, or acquired atresia of the vulva, and one case, at least, has 
been mistaken for an hermaphrodite. Under such circumstances an 
attempt should be made to pass the sound into the bladder, and by 
introducing the finger or another sound into the rectum the pres- 
ence or absence of a vagina may possibly be made out. If the 
patient is an adult, and the case one of imperforate hymen, men- 



626 DISEASES OF WOMEN". 

strual fluid will probably be found in tlie vagina. Should there still 
remain any doubt, the only resource would be to try dilatation of 
the introitus vaginae, and see what lies beyond it. 

Treatment. — The treatment may be either radical or palliative. 
Where there is an entire absence of the urethra, with the existence 
of vesical fissure, or in persistence of the sinus uro-genitalis with 
partially developed urethra, the production of an artificial canal has 
been suggested. This may be done by dissecting from the vaginal 
wall a flap from under the symphysis. It should be about one third 
of an inch in breadth, and after being turned with its epithelial sur- 
face inward, should be united with the freshened edges of the vesi- 
cal fissure. It is objected by some authors that even if the opera- 
tion is successful, the patient will be but little benefited, the new 
urethra being devoid of muscular tissue, and consequently lacking 
the power of contraction. The passing of urine into the vagina, 
however, will be done away with, and the general condition of the 
patient will be greatly improved by the use of an artificial urinal. 
This of itself is a great point in favor of the operation. 

Heppner believes that the method of producing an artificial ure- 
thra by trocar puncture of the soft tissues and sewing up the vesical 
fissure is dangerous, because vessels of considerable size are liable 
to be injured ; a further disadvantage being that the canal tends to 
close. The cases of Carbol and Middleton bearing on this point he 
puts aside as unreliable. He moreover maintains that reduction of 
the vesical fissure to the size of the urethra is a disadvantage, since 
the anterior wall of the fissure will be without any muscular tissue. 
The experience of those who have treated fistula has been, so far as 
he knows, that linear clefts, even of greater caliber, hold back the 
urine better than round openings of smaller size, the former allow- 
ing more complete coaptation of the edges. 

In Heppner's case, there being only nocturnal incontinence, he 
contented himself with applying a bandage in the manner suggested 
by Sawostitzki. A girdle was put around the lower part of the ab- 
domen, and to it was fastened a little olive-shaped compress, by 
means of a steel spring, something after the manner of a truss. 
When put into the vagina this compress pushed the posterior vesi- 
cal wall toward the pubic symphysis, thus closing the opening and 
relieving the incontinence. The patient soon became used to the 
instrument, and obtained great relief from it. 

Atresia of the urethra can only be cured by operation. Carbol 
operated in 1550 on a servant-girl in Beaucaire, who had suffered 
from this difiiculty from her youth up. The urine flowed from a 



MALFORMATIONS OF THE BLADDER AND URETHRA. 627 

coxcomb-like growth, some four fingers in lengtb, at the umbilicus. 
The stench that arose from her body was intolerable. Carbol per- 
forated in the region of the urethra, and successfully removed the 
growth at the umbilicus by ligation. 

In the case of a child, seven days old, who had never passed 
urine, and whose bladder was enormously distended, Middleton 
pushed a trocar through in the direction of the absent urethra, 
emptied the bladder, and kept the opening pervious. 

Oberteufer's patient, who had atresia urethrge and urachal fistula, 
relieved herself somewhat by wearing a large sponge over the um- 
bilicus secured in position by a bandage. In such cases as this the 
apparatus usually employed in urinary fistula should be made use of. 



MALFORMATIONS OF THE BLADDER. 

These malformations follow the general rule of being in most in- 
stances due to some defect in the normal process of development. 
Those which are of sufficient importance and especially demand atten- 
tion are : 

1. Fissure. — The most frequent and prominent anomaly of devel- 
opment in the bladder is that of fissure. It consists in partial or 
complete absence of the anterior vesical wall, and is usually accom- 
panied by malformations of other organs. The anus and umbilicus 
in these cases, as a rule, lie nearer than normal to the pubic symphy- 
sis. 

There are various grades of this affection. There may be sim- 
ple fissure of the lower part of the bladder, with the opening about 
three quarters of an inch in breadth, as has been seen by Desault, 
Palletta, Gosselin, Coates, and others. In the cases reported by 
them the symphysis pubis was but loosely united. There may also 
be fissure of the clitoris. 

A higher grade of this malformation is that in which the fissure 
is near the umbilicus, the lower part of the pelvic cavity and the 
pubic symphysis being closed, and the lower part of the bladder, 
urethra, and external genitals normal. This condition is next in 
order to patency of the urachus — fistula-vesico-umbili calls. In the 
latter case, the urachus may remain pervious its entire length, and 
open into the ring of the umbilicus. 

The highest grade is that in which the whole antei'ior wall of the 
bladder seems to be absent. In these cases the inferior abdominal 
region is generally much shorter, and the umbilicus nearer the base 
of the pelvis. * The abdominal walls are divided, and the resultant 



628 DISEASES OF WOMEK 

fissure is filled up by the bladder-wall, the mucous merabrane of 
which is puffed out and red, and gradually merges into the skin of 
the abdomen. It is often wrinkled, thickened, moist, shiny, and the 
edges dry and covered with thickened epidermis. 

On each side of the lower portion of the everted bladder are situ- 
ated the orifices of the ureters. They usually appear as little ex- 
crescences, but are sometimes hidden in the folds of the membrane. 
The pubic bones are imperfectly developed, and the pubic symphy- 
sis never closed, save by a hgamentous band, the bones lying from 
haK an inch to three inches apart. These separations of the pubic 
bones, as has been shown by Dubois, Dapuytren, Mery, and Littre, 
are congenital. 

As a rule, in such cases, the urethra is absent. The clitoris is 
either divided with a portion on each side of the upper part of the 
imperfectly formed labia, or there may remain but a trace of it, or, 
again, it may be entirely absent. The hymen can be seen beneath 
the fissure. The vagina may be absent, as in cases observed by 
Herder and Eschenbach, and the uterus may be divided by a septum. 
Atresia vaginse and imperfect ovaries have also been found in such 
cases. This grade is known as eversio or exstropia vesicae. 

If there is simply a fissure of the bladder the organ may be pro- 
lapsed through the fissure (inversio vesicse cum prolapsu per fis- 
suram). This must be distinguished from inversio vesicoe cum pro- 
lapsu per urethram and exstropia per urachum. That this may be 
clearly understood, it must be remembered that inversion of the 
bladder occurs in three ways : First, by a protrusion of the organ 
through an opening or fissure in its own walls (the form now under 
discussion) ; second, by an inversion through the urethra ; and third, 
by an inversion through a pervious urachus. 

The ureters, as a rule, are considerably widened. Isenflamm 
found them dilated from three quarters of an inch to more than an 
inch ; Petit as much as two inches ; Flagani and Bailie found them 
to be four inches ; Desault three inches ; and Littre two and one 
half inches, and containing small calculi. Their course, as a rule, is 
changed, sinking deeper into the pelvis, and thence rising up into 
the bladder. There are, however, exceptions to their enlargement. 
Bonn, in one case, observed as long ago as in 1818, found their length 
and breadth normal. Winckel also speaks of a case where both kid- 
neys and ureters were normal. 

The anomalies known as epi- and ana-spadias belong under the 
head of vesical fissures. 

2o Double Bladder. — Cases of double bladder, says Yoss, are be- 



MALFORMATIONS OF THE BLADDER AND URETHRA. 629 

coming quite rare as pathological knowledge advances, for many 
of these were probably cases of pathological division of the vaginal 
wall. 

Mollinetti mentions, in his '' Anatomico-Pathological Disserta- 
tions," the case of a woman wdth five bladders, five kidneys, and six 
ureters. Blasius describes a case of perfect division of the bladder 
into two separate halves, which at the vesical neck ended in one 
common urethra. Each bladder had one ureter. The subject was a 
male adult. Isaac Cattier has found this anomaly in little children. 
One case was that of a child fifteen days old. The bladders were 
separated by the rectum to such a degree that a finger could be laid 
between them. Sommering found this condition in a child two 
months old. In one that was born miserably nourished, and lived 
but twelve hours, Schatz found perfect division of the whole geni- 
tal apparatus, double bladder, and double congenital vesico- vaginal 
fistula. In double bladder, the double allantois, instead of forming 
one passage, forms two, with a ureter opening into each. 

Testa gives a case of perfect separation by the vaginal wall. 
Scanzoni found, in making a post-mortem examination on the body 
of a tuberculous woman, a division of the bladder into two lateral 
halves. He does not say, however, whether the division was com- 
plete or whether the septum was pervious. 

Sometimes horizontal septa are formed that are due probably to 
a crumphng up of a part of the bladder while growing, or a com- 
mencing closure of the urachus lower down than usual. 

Koser, of Marburg, had a case of urachal cyst, which, when 
enormously distended, reached as far as the umbilicus. By means 
of a small connection with the bladder it was filled when that organ 
contracted, and, finally, it and the bladder were emptied by contrac- 
tion of the abdominal muscles. Yesical cysts and diverticula may 
be confounded with the anomalies resulting from arrest of devel- 
opment. 

The slightest grade of anomaly is that in which, as Chonsky has 
observed, there is no full septum, but simply a band or seam, appar- 
ent externally. 

Etiologij, — The original urinary sac of the embryo, it will be 
remembered, is the allantois, whicli takes its oi'igin as a oid'de-saG 
from the rectum, and is, consequently, an offshoot of the intestine. 
It is formed by the bagging of the cloaca, which bagging is due to 
the collection there of urine from the primitive kidneys. This allan- 
tois, especially in the human species, is double, and remains only a 
short time. After the fourth week of embryonic life, the layei-s 



630 DISEASES OF WOMEK 

coalesce, and the di\^ision ceases. Yet tlie original double form may 
remain for some time beyond the normal period, if there are anv 
hindrances to union. 

Roose and Creve maintain that the cause of this malformation is 
the failure of the pubic bones to unite. Meckel takes exception to 
this, and says that the bladder in its primitive condition shows itself 
as a simple, plain sm-face, which only becomes a cavity by the grow- 
ing toward each other and union of its edges. Duncan and, at a 
later date, A. Bonn, and, still later, B. S. Schultze and Thiersch, 
held that vesical fissure had, as its primary cause, an atresia of the 
urethra, with great dilatation of the bladder, the distended organ 
pushing aside, first, the recti muscles, later, the cartilaginous pubic 
bones, and, finally, bursting. E. Rose, on the contrary, maintains 
that these cases of bladder-fissure are cases of perpetuated urachus, 
and are due to developmental failure in the bladder itself, remain- 
ing open as far as the urethra. He says positively that the edges of 
recent preparations of the bladder show a fresli, smooth surface, and 
that there is no trace whatever of any cicatrix or callosity. He 
mentions one case of tearing and rupture where the evidences were 
plainly to be seen. Moergelin, who was unable to find proof of 
rupture as a cause of this anomaly, says that, if there was a quan- 
tity of urine in the bladder, greatly distending it, there would be 
a reopening of the urachus or a bursting into the abdominal cavity, 
rather than a rupture through the abdominal walls. He looks favor- 
ably on the idea of a bursting of the allantois before the abdominal 
w^alls have closed in front of it. 

Against this, however, is the fact that Hecker extracted a foetus 
with atresia, having an enormously dilated, unruptured bladder. He 
found in the abdominal walls a cicatrized sht covered by perito- 
naeum. This makes manifest the possibility of a rupture of the ab- 
dominal walls, and also of the bladder, occurring at a comparatively 
late date. 

In the case related by Rose no information is given as to whether 
there was a normal umbilical cord or not, whether there was any 
urachal fistula, whether the abdominal ring was closed entirely, or 
whether the fissure was confined to the inferior part of the anterior 
vesical wall, as described by Gosselin, Bertet, and others. In their 
cases it was not possible for the fissure to have originated by the re- 
opening of the urachus. In any event, most of the late authors are 
agreed that hindrance to the outflow of urine has most to do with the 
production of this anomaly, and it may, as Rose has shown, and as has 
been said before, arise from atresia or absolute absence of the urethra. 



MALFORMATIONS OF THE BLADDER AND UEETHRA. G31 

Another possible mode of causation of this malformation is by 
the falling of some of the larger abdominal organs into the pelvic 
cavity, compressing the m-ethra, and hindering its formation. E. 
Rose once found the right kidney in the pelvis, and Winckel has 
recorded a case described by one of his students, Dr. Kriiger, where 
the left lobe of a considerably enlarged liver and a quantity of small 
intestines were so tightly wedged into the pelvis as to cause marked 
bulging of the perinseum. Such a condition, coming at a time 
when the urachus and urethral end of the bladder are hrmly closed, 
must tend to form a vesical fissure. 

Perfect eversion of the bladder may, however, be found at a very 
early date, even before the two halves of the allantois are joined, as 
in cases related by Friedlander, E. Eose, and Winckel. Lying be- 
tween, and in front of the single- or double-everted bladder or blad- 
ders, there are sometimes found, as in E-ose's and Winckel's cases, 
bands of perforated skin-folds, behind which a sound may be passed. 
Their presence may be explained in this way : That the underlying 
serous connective tissue (Rathke's membrana reuniens inferior), 
which closes the abdominal cavity before the development of the 
skin and muscular system, is the covering of all urachal fistulge, open 
bladders, and persistent allantois. Then, where the urine pressure 
is the greatest, the bladders move upon each other, so that no further 
development can take place between them ; but the abdominal plates 
develop themselves around and between them. 

This intermediate development, owing to the imperfection of 
the lower connective tissue, becomes a band or rim where the two 
conically formed bladders push together, so that they can not become 
a symmetrical whole, but have an intermediate arch. In these cases 
the cause probably lies in the patency of the urachus and the eversion 
of the bladder ; also the open condition of the abdominal walls, inter- 
ference with the development of the lower parts of the musculi recti, 
and, later, the imperfect development of the pelvis. 

There can, however, be a fissure of the abdominal walls without 
a fissure of the bladder, the closed organ protruding from the alv 
dominal fissure (ectopia vesicae). 

Lately Ahlfeld has brought forward the hypothesis that evei*sion 
of the bladder is complicated with and dependent on a pulling down- 
ward of the ductus omphalo-meseraicus, making an obtuse angle in- 
feriorly, whereby, the rectum being pushed forward, it pushes the 
inferior wall of the allantois before it. Communication between the 
rectum and the allantois ceases, and the allantois, becoming enor- 
mously distended, bursts. Ruge and Fleischer contend that in this 



632 DISEASES OF WOMEX. 

affection the duct of the iimbiHcal vesicle is implicated, and hold 
that the tense cord (duct) in question is a continuation of the urachns. 

Winckel is of the opinion that bursting of the bladder at an 
early stage from urine-pressure is the weightiest cause in the produc- 
tion of bladder fissure. Against the idea of Rose, which is that 
eversio vesicae does not take place from rupture, Winckel says that 
the presence of scars is not absolutely necessary to prove the point, 
for the abdominal walls are not yet joined, and therefore can not be 
ruptured ; and, moreover, he has often seen children immediately 
after birth in whom the umbilical cord was normal, and yet an ever- 
sion of the bladder existed. He raises the query as to why we can 
not have rupture of the bladder at an early period, since we know 
that it occurs later in life, as in women with retroflexion of the 
gravid uterus. 

Another fact that he advances in favor of the view that rupture 
of the bladder is due to urethral obstruction is that it occurs oftener 
in males than in females, the former having a canal much more favor- 
able to such obstruction, for, of sixteen cases of vesico-umbilical fist- 
ula, given by Stadtfeldt, fourteen were males and two females. Dr. 
Wunder, of Altenberg, in 1831 observed the cases of two boys, aged 
respectively eight and eleven, with congenital eversion of the blad- 
der. It is interesting to note that their mothers were sisters. 

The various causes that give rise to vesical fissure produce also 
imperfectly developed pelvic bones, dislocation of the head of the 
femur, and other malformations from pressure. The excessive dilata- 
tion of the bladder drives the horizontal rami of the pubes asunder, 
and the changed direction and imperfect growth of the pelvic bones 
cause a lessened acetabular circumference and consequent slipping 
out of the head of the femur. Thus does Yoss explain the disloca- 
tion occurring in one of his cases. 

It will be found on touching the red mucous membrane of an 
exposed bladder that it is exceedingly sensitive. In such a case the 
urine may be seen oozing from the ureters and dribbling over the 
surface. The mucous membrane is often protruded and wrinkled 
up by the movements of the bowels, and can, in case the bladder- 
opening is great, be inverted through the fissure (inversio vesicae per 
fissuram) or through the urachus (inversio vesicae per urachum). If 
the fissure is small it may remain for years without any inversion. 
If the prolapsed mucous membrane is replaced and indirect pressure 
is made on the dilated ureters, the urine will spurt from the ureteric 
orifices. 

Sometimes these patients have partial control over their urine ; 



MALFORMATIONS OF THE BLADDER AND URETHRA. 683 

as in cases where an umbilical hernia exists with umbilical fissure, 
the posterior wall of the bladder being forced into the opening 
pings it up. Such a case is described by Paget. The hernial sac, 
which was about the size of a goose-egg, completely plugged the 
umbilical f oram en by pressing firmly against the posterior bladder- 
wall. If the patient desired to urinate, the contraction of the blad- 
der caused a gradual disappearance of the hernial tumor ; and when 
it had entirely disappeared he passed urine from the umbilicus and 
then through the urethra. After the urethral flow began the stream 
from the umbilicus ceased, and no urine passed at that point unless 
strong pressure was made upon the abdomen. 

Another way in which partial retention may be accomplished in 
imperfect eversion is by the greatly thickened muscular walls acting 
as a sort of sphincter. Such a case given by Yoss is that of a female 
child, twenty months old. When lying down and quiet, the urine 
did not flow away so freely. The bladder-wall was nearly one inch 
in thickness, and the ureters, though three inches broad, were greatly 
narrowed at their point of entrance into the bladder. 

In fissures situated low down there may be coincident inguinal 
hernia, as is illustrated by a case related by Bertet. This compHca- 
tion may act so as to aid in the retention of urine. From the con- 
stant flow of urine, the inferior end of the fissure and neighboring 
parts become moist, red, eroded, and sometimes incrusted and ulcer- 
ated. There are various painful sensations, as itching and burning, 
and the patient becomes a nuisance to herself and to those about her 
from the offensive urinous odor that is constantly given off. 

The edges of the mucous membrane in time become changed, 
and resemble skin in appearance. At other points, oftentimes, the 
membrane is much changed, having upon its surface loose, villous 
growths, that bleed readily when touched, and give the impression 
of a malignant new-formation. 

By reason of a separation of the pelvic bones there is an irregu- 
lar, uncertain gait. The pelvic diametric proportions, as observed 
by Moergelin, are in these cases much changed, the transverse being 
much greater than the antero-posterior, the dissimilarity increasing 
as age advances, the proportion being sometimes trebled. Women 
with these troubles, however, have borne children. 

A close inspection of the ureteric openings being possible in 
these cases, the interesting observation may be made that in action 
the kidneys seem quite independent, the one of the other, the right 
discharging urine and the left none, or the reverse, or both may dis- 
charge together. 



634 DISEASES OF WOMEN". 

Diagnosis. — the diagnosis of urachal fistula is comparatively 
easy, for the affection is at once recognized by finding the ureteric 
orifices with the urine flowing from them. 

As to frequency, the following statistics are of importance : 

In 12,689 new-born children, Sickles found this malformation to 
occur twice in twenty-seven cases of developmental anomalies. 

In thirty-five hundred births occurring in the Dresden Institute, 
from 1872 to 1875, Winckel saw one case. 

Yelpeau, in the year 1833, mentions seeing and finding on record 
more than one hundred cases of this kind. Percy says that he has 
seen it twenty times in his own practice. Winckel saw five cases, 
three of which were girls, and two boys. Phillips saw twenty-one 
cases, all girls ; but in Wood's twenty cases, only two were girls. 

Prognosis. — The prognosis is usually unfavorable. The children 
are weak and puny, and, as a rule, die early. They are, however, 
seldom destroyed by the fissure itself. Many of them are born liv- 
ing, and can be kept alive, and some attain a fair age. Lebert saw 
in Salpetriere Hospital, Paris, an old woman with this affection. 
Operative procedures and the various apparatus to prevent trick- 
ling of urine are of little avail. This, however, is only the case 
in total eversion. Urachal fistulee, simple fistulse, above the pubic 
symphysis, and even those situated inferiorly, where the pubic 
bones are united, may be readily cm-ed by the ordinary operation for 
fistula. 

Treatment. — Stadtfeldt operated in eight cases of urachal fistula, 
in seven of which he obtained perfect healing. In deep fistula he 
recommends freshening of the edges of the skin and mucous mem- 
brane, and attempting union by the first intention. In cases where 
the edges extrude themselves very much, he puts on either a clamp 
or ligature. 

"Winckel favors operative procedure since, in that way, the ab- 
normal protrusion can be removed. Sometimes, as recommended by 
Paget, it will be sufficient to freshen the edges, put in insect-pins, 
ligature, and union may be expected in from two to four weeks. 

In fissura vesicae, superior or inferior, an attempt might be made 
to draw the edges together, and even to loosen the skin in front by 
incision, so as to remove traction from the edges. In that case it 
will be necessary to freshen the edges and put in sutures. The re- 
sult, unfortunately, is not uniformly successful. 

In earlier times, in cases of true eversion of the bladder, no one 
dared to operate, and the only alleviation granted to the patient 
was such as could be obtained by a properly-adapted urinal. Nu- 



MALFORMATIONS OF THE BLADDER AND URETHRA. 635 

meroiis appliances have been invented for this purpose, some of 
them verj useful. 

Gerdy was the first to operate for eversion by closure. Failing 
to bring an inverted bladder back into place, he tried to form a suf- 
ficient sac by partial excision of the ureters. The patient, a man, 
was attacked with peritonitis and nephritis, and died. 

Jules Roux, in 1853, proposed cutting out the ureters, and unit- 
ing them with the rectum. Simon tried this once, and succeeded ; 
but the patient died six months after from peritonitis and exhaus- 
tion. At a later date, he again attempted to treat this malforma- 
tion by operative procedures. He made one inferior and two lateral 
flaps, but these became gangrenous. Ten years later, these attempts 
were more successfully made by John Wood and Holmes, and their 
results recorded by Podruzski. 

The first one, however, who obtained a perfect result was Dr. 
Daniel Ayres, of Brooklyn. He cut a long flap from the under and 
lower side of the abdominal walls, turned the skin-side in, and 
united it with both edges of the bladder. A full account of this 
case will be found at the close of this chapter. Since then I have 
seen three cases, but as they were not patients of mine I had no 
opportunity to interfere surgically in their treatment. 

Subsequently, Wood operated on a girl one year and a half old, 
whose bladder-fissure was continuous with the uro-genital sinus, so 
that the os and cervix uteri were always wet. He raised one flap 
from the neighborhood of the umbilicus, and another from the 
soft parts, and turning the skin-side in, covered them with a larger 
flap from the other side. The mucous membrane, however, pushed 
through inferiorly, and broke the fresh adhesions. 

Ashhurst's case was more successful. He cut a piece from 
under the umbilicus, and joined it with two flaps from the sides 
(they being somewhat turned) so that their upper edges met each 
other in the median line. They were joined by sutures, and through 
each side of the upper flaps two pieces of malleable iron-wire were 
carried, then drawn through the lateral flaps, and twisted over little 
rolls of plaster. Traction was thus reheved. The flaps healed by 
the first intention. The sutures were removed on the eighth day. 
The rest of the wound healed by granulation. When in the up- 
right position, incontinence of urine still continued ; but when lying 
upon her back, the patient was able to retain urine for about two 
hours, her general condition being thus greatly improved. 

Ashhurst gives a resume of twenty cases of eversio vesicip, oper- 
ated on up to his time. Fourteen of these were successful — Ayres, 
42 



DISEASES OF WOMEN". 

Holmes, Wood, Morey, and Earker, each being credited with one. 
Three were unsuccessful, bj Holmes and Wood ; and three resulted 
fatally, by Kichard, Pancoast, and Wood. In the last two death 
resulted from causes other than the operation. 

In aU cases when the skin is turned in, the growth of hair al- 
ready present or to come will be apt to give rise to incrustations. 
Thiersch, in his six cases, allowed the flaps to granulate on their raw 
surface before applying them. When the flap-union is perfect, he 
advises closing completely the upper part of the bladder. 

The diagnosis of double bladder may be made by urethral dilata- 
tion and exploration by the finger and catheter. 

Destruction of the bladder-septa is not to be thought of. In case 
of the existence of urachal cyst causing difficult urination, one might 
try extirpation of the cyst by cutting into the abdominal walls, and 
after freshening their edges unite them with those of the bladder. 

ILLUSTRATIVE CASES. 

Extroversion of the Urinary Bladder. (By Daniel Ay res, M. D., 
LL. D.) — The patient was admitted to the Long Island College Hos- 
pital, November 1, 1858, and a history of the case recorded by the 
house surgeon. Dr. Ostrander. 

She is twenty-eight years of age, bom of healthy parents, both 
of whom were free from deformity ; her height is below the aver- 
age of females, and she is unmarried. She declares her health to 
have been always good, appetite and digestion excellent, bowels 
regular, and the catamenia in all respects normal. 

She states that, on the 5th of July preceding, she was delivered 
of a well-developed child, having carried it to maturity without 
extraordinary difficulty. Labor commenced v^dth free haemorrhage 
(footling presentation), and lasted two hours, at the end of which 
time the child was born, having died in process of delivery. Peri- 
nseum uninjured. She reports having made a tolerable recovery, 
though for a long time weak, and her present appearance is some- 
what angemic. 

Shortly after she began walking about symptoms of prolapsus 
uteri came on, becoming gradually worse, until the organ projected 
external to the vulva, attended with dorsal, dragging pain, difficulty 
of locomotion, and gastric disturbance. 

In quest of relief, she entered the Brooklyn City Hospital on 
the 1st of September following her confinement, and remained there 
one month. Here she states that a variety of pessaries were tried, 
none of which could be retained, and finally a surgical operation 



MALFORMATIONS OF THE BLADDER AND URETHRA. 637 

was performed, tlie nature and character of which is not very appar- 
ent. A short article, descriptive of this case, appeared in the " Vir- 
ginia Medical Journal" for January, 1859, written by the house 
surgeon of that institution. The writer states that an attempt was 
made to retain the prolapsed uterus " by removing an inch of mu- 
cous membrane from the bottom and sides of the vulva, and unit- 
ing them by two figure-of-eight sutures, which were removed on 
the sixth day, when no adhesion was found to have taken place." 
The writer continues : " The patient was allowed to get up on the 
fourteenth day, when the prolapsus was found to exist nearly as 
much as before," etc. 

It is obvious that no effort was made to relieve the congenital 
deformity, and that she was discharged in much the same condition 
as when she entered. 

Finally, a species of stem-pessary was contrived which was in- 
tended to support the uterus, while kept in position by strings 
passed around the thighs. This, however, proved very inefficient — 
the uterus slipping by the instrument upon the slightest extra exer- 
tion. Moreover, the parts had now assumed an irritable condition, 
partly due to increased friction of the apparatus, and undue attention 
to cleanliness, added to the causes already noted ; altogether, her de- 
plorable condition was scarcely susceptible of being made worse. 

I may here remark that the figures, both before and after the 
operation, have been photographed from accurate plaster- casts, taken 
directly from the patient — a very difficult and delicate procedure, 
for which I am much indebted to the skill and kindness of my 
colleague Dr. Bauer, and our valuable assistant, Mr. J. F. Esslinger. 

Fig. 221 is an exact representation of the parts at the time of 
presentation to the clinical class of the Long Island College Hospi- 
tal, for the purpose of critical examination. The prolapsus, having 
been carefully and completely reduced, was found to retain its place 
so long as the patient maintained the recumbent position. 

The distance between pubic abutments was estimated at about 
three inches. 

The bladder (a) formed an oval, elliptical tumor, mammillated 
upon the surface, which in the recumbent position measured two 
inches in its long, and one inch and a quarter in its short diame- 
ter. This was soft, elastic, or bright vermilion color, and covered 
with a thick tenacious mucus ; bleeding readily when rudely han- 
dled, and so exquisitely sensitive, that while under the full infiuence 
of chloroform, and insensible to the knife, a sponge passed over the 
exposed bladder excited reflex motions. 



638 



DISEASES OF WOMEN. 



The integument immediately surrounding tlie bladder was found 
red and puckered, but very soft, delicate, and free from hair be- 
tween the bladder and point of sternum. The labia majora (c>, o,) 

thick, flesh J, and luxuri- 
-.,. ^ ' ' antly covered with hair, 

were gathered into folds 
swelling awaj toward 
either thigh ; these were 
carefully shaved previous 
to taking the cast and per- 
forming the operation. 

The nymphae occu- 
pied isolated positions 
on each side of the vul- 
va, and are designated in 
all the figures by the let- 
ters h, h. 

Between these and 
the vagina below no trace 
of clitoris or urethra could 
be distinguished, but the 
whole surface was cov- 
ered with mucous mem- 
brane, continuous with 
the vaginal lining. 

Here, then, we had 
to contend with two formidable difficulties, either of which was a 
problem in itself, viz., aggravated prolapsus from an entire ab- 
sence of an anterior support, added to the original congenital mal- 
formation. 

To form an estimate of the value attached to surgical operations 
in these cases, we can not do better than quote the opinion of Prof. 
Erichsen, of University College, London. Having collected the 
experience of the profession on this topic, his eminent position at 
the center of surgical science, added to his well-kno^vn and exten- 
sively recognized erudition, renders him at once a reliable and com- 
pendious authority on the subject. 

" This malformation," says he, " is incurable. Operations have 
been planned, and performed with a view of closing in the exposed 
bladder by plastic procedm-es, but they have never proved success- 
ful, and have terminated in some instances in the patient's death ; 
they do not, therefore, afford much encouragement for repetition." 




Fig. 221. — ExtroTersion of the bladder, a, Bladder 
exposed, forming a bright vermilion tumor ; 6, 6, 
labia minora ; o, o, above labia majora ; c, vagina ; 
J, anus. 



MALFORMATIONS OF THE BLADDER AND URETHRA. 639 






So unsatisfactory have been the results of these operations that 
the profession has not been favored with their general plan, their 
details, nor the causes of 

failure. It must be evi- ^ - ' '^^^^^^--^ri ^ !___ 

dent, however, that op- 
erations based upon the 
principles of plastic sur- 
gery alone offer pros- 
pects of success. 

The most probable 
source of failure, and 
one which challenged 
our early attention, was 
the disastrous result to 
be apprehended from 
urinary infiltration, 

which, by its irritating 
character, would neces- 
sarily destroy all pros- 
pect of union, if it did 
not induce extensive 
sloughing of the abdom- 
inal parietes ; peritonitis 
and purulent phlebitis 

are likewise probable sources of danger, unless carefully guarded 
against. Indeed, these may all become inevitable consequences of 
attempting to accomplish too much at one time ; and it was there- 
fore determined to arrange our proceedings with a special \^ew, if 
possible, to avoid them. The indications which it was proposed to 
follow were : 

1. To form an anterior wall for the exposed bladder. 

2. To restore the urinary canal. 

3. To establish the anterior fourchette of the vulva. 

4. To supply means to prevent the prolapsus, and to collect the 
renal secretions. 

The delicate character of the integument above the bladder and 
its well-known transmutability into the conditions of a mucous mem- 
brane peculiarly adapted it to supply the anterior cystic wall, and 
thus fulfill the primary indication. 

With these objects in view, the operative proceedings were di- 
vided into two stages. 

The first consisted in raising a flap from the anterior portion of 



Fig. 



222. — e, Linear cicatrix, formed by the flaps cov- 
ering the bladder ; h, b, nymphse brought together, 
and inclosed by the vulva. 



640 



DISEASES OF WOMEN". 



the abdomen, including the superficial fascia, turning its cuticular 
surface down over the exposed bladder as far as its inferior border, 
and securing the lateral unioli of the flap in that position, while a 
free exit below was maintained for the urinary discharge ; an im- 
portant result, still further assisted bj the dependent situation of 
the outlet of the ureters already alluded to. 

By these means it was proposed to accustom the highly sensitive 
bladder to a gradual and methodical compression while the flap it- 
self was insured ample space to undergo such swelling as might be 
anticipated from its new position and the unusual stimulation of a 
new secretion. Time was likewise given for the necessary trans- 
mutation of tissues to make some progress. 

The steps of this procedure will perhaps be better understood 

by a more detailed state- 
ment of the first operation, 
in connection with the di- 
agrammatic plates, Figs. 
223 and 224. 

It was performed on 
the 16th of 1^0 vember last, 
the patient being thor- 
oughly under the influ- 
ence of chloroform, and a 
sugar - loaf - shaped flap 
having been previously 
marked out upon the ab- 
dominal integument ; its 
base, E, F, three inches in 
width, was situated three 
fourths of an inch above 
the cystic tumor, and ex- 
tended five inches in 
length, with its apex to- 
ward the ensiform carti- 
F (Fig. 223), indicates its form. 




Fig. 223. — a, Bladder, covered by deep 
nymphae ; c, vagina ; d, anus. 



lage. The dark line E, H, G, I 
position, and the line of incision. 

This flap being left suflBciently large to meet the elevated form 
of the bladder and allow for shrinkage, was quickly but carefully 
separated from its cellular attachments, down to the line E, F, 
while two lateral incisions, E, J, and F, K, were continued directly 
downward and toward the nymphse, to serve as beds for receiving 
the sides of the new fiap. 



MALFORMATIONS OF THE BLADDER AND URETHRA. 641 



The integuments covering the lateral and inferior portions of the 
abdomen, extending from G to J on one side, and from G to K on 
the other, were now sufficiently separated from their cellular attach- 
ments to the muscles beneath to insure their sliding freely, and meet- 
ing without tension at the mesial line, G, N (Fig. 224). When 
brought into this position they completely covered from view the 
raw surface of the flap already turned over, and investing the blad- 
der, with the exception 
of a triangular space, 
J, N, K (Fig. 224), formed 
by the coaptation of the 
lateral flaps ; this was 
temporarily covered by 
reflecting back upon it- 
self the corresponding tri- 
angular free end of the 
deep flap, J, C, K (Fig. 
224), and attaching it 
along the line, J, N, K. 
Numerous points of in- 
terrupted suture were 
used to retain the parts 
in situ^ assisted by long 
strips of adhesive plaster, 
compresses, and a reten- 
tive bandage around the 
body. It will be observed 
that the lower portion of 

the cystic tumor was thus temporarily left free and partially ex- 
posed, while no portion of cut or denuded surface remained uncov- 
ered. 

The patient received a large dose of opium, and was strictly 
maintained in the recumbent position upon a bed, properly pro- 
tected; such additional measures being adopted as would secure 
cleanliness. 

As the parts subjected to operation began to swell, she com- 
plained of irritation and pressure upon the bladder, which, however, 
were promptly met with morphine alone, and subsided in the course 
of a few days. Now was exhibited the great importance of leaWng 
the tumor partially uncovered, while all the cut surfaces were in 
close contact, and thus freed from the action of irritating secretions ; 
important facts duly dwelt upon and recently enforced with great 




Bladder ; b, b, nymphse 
anus. 



c, vagina ; d, 



642 DISEASES OF TVOXIEX. 

stress by tlie distingnished Prof. Svnie, of Edinburgli, wliose con- 
tributions to the surgical treatment of the urinary organs have alone 
placed both heroispheres under permanent obligation to him. 

On the fourth day after the operation all sutures were removed, 
the wounds having healed by fii'st intention or primary adhesion, 
with the exception of a spot the size of a ten-cent piece, situated 
jnst above the point of the triangle, and where the deep flap had 
been reflected over the bladder. At this point the lateral abdominal 
flaps were necessarily raised up from the tissues beneath, and could 
not be brought into contact even by the use of compresses. This, 
however, granulated kindly, and was nearly cicatrized on the Yth of 
December, when the second and last operation was performed, as 
follows : 

The patient being under the influence of chloroform the lower 
triangular flap, J, X, K (Fig. 224), was dissected from its recent and 
temporary attachments, both lateral aud deep, and turned down over 
the vulva as indicated by the dotted line, J, C, K. 

Two incisions, J, L, and K, M, were now carried from the ex- 
ternal angles of this triangle, perpendicularly toward and terminat- 
ing just behind the nymphte, B, B. 

The lateral flaps bounded by the lines X, J, L, and N, K, M, 
and including the labia majora, were then freely dissected from over 
the abutments of the pubic bones until they could be readily shd to 
meet each other at the central line, X, C, which, being a continua- 
tion of the line G, X, reduced the whole to a single linear wound, 
occupying the '*linea alba." (See Hg. 222.) 

During the operation several arterial branches bled freely, and 
were an-ested by torsion and the free application of ice, after 
which the flaps were confined at the mesial line by points of inter- 
rupted suture, the most inferior one, viz., at L. and ^I, being made 
to include the apex C, of the triangular flap. 

Fearing to depend on sutures alone to secure the approximated 
flaps, and the use of adhesive plaster being excluded by the irregu- 
larity and position of the parts, the whole surface between the points 
of sutui'e was hermetically incased by strips of patent lint, soahed 
in collodion and accm-ately applied. In addition to this, pieces of 
muslin were by the same method firmly attached to the labia majora, 
at some distance from the mesial hne, and to these sutures silk was 
fastened in such manner as to form a lacing across and over the 
wound. By means of this dressing all tension was removed from 
the sutures, urine was totally excluded, while rapid and perfect ad- 
hesion soon followed. 



MALFORMATIONS OF THE BLADDER AND URETHRA. 643 

Thus a urinary canal was formed which would admit the little 
finger to be passed up one inch and a half. The anterior four- 
chette of the vulva was firmly established, and the mons veneris as- 
sumed its prominent and natural appearance. 

The last cast of the parts representing her present condition 
(Fig. 222) was taken on the 4th of January, 1859, previous to which 
time, the parts being all firmly united, she was permitted freely to 
walk about, and left the hospital to spend the holidays with her 
friends. No artificial support whatever was applied, in order to as- 
certain how far the operation would succeed in preventing the pro- 
lapsus. 

After a severe test, the anterior fold of the vagina alone de- 
scended, and that for a short distance, forming a pale, oedematous 
tumor, occupying the vulva, about the size of an English walnut. 
The anterior fourchette of the vulva remaining firm and resisting, a 
light, oval pessary, made of vulcanized rubber, and perforated, was 
introduced into the vagina and readily retained in situ. After thor- 
ough trial, this was found to support the parts completely, and with- 
out the slightest uneasiness, even under active exertion and straining. 

This was a better result than had been anticipated, inasmuch as 
it was intended to rely mainly upon a disk-shaped pessary, sup- 
ported by a foot attached to a simple apparatus which we had con- 
structed to act as a reservoir for the urine. 

January 20, 1859. The patient was again examined at the hos- 
pital, in the presence of a number of medical gentlemen, she having 
walked a distance of two miles without experiencing any incon- 
venience. The parts were all found sound and firm, and her gen- 
eral health and spirits much improved. 

Patent ITrachus with Calculus. (H. D. Yosburgh, M. D., " New 
York Medical Kecord," September 22, 1877.) — Several months ago 
I was called to see J. H. B., fifty, a mechanic, of spare habit, and 
always in good health. He complained of soreness and constant 
pain at the umbilicus, and on examination I found the natural de- 
pression filled up by a rounded tumor, apparently the natural tissue 
enlarged by swelling. There was also circumscribed hardness of the 
tissues around the umbilicus. The parts were red and very tender 
to the touch, having every appearance of an ordinary erysipelas. 

At the time of my visit he told me that a score or more of years 
before, after a similar experience, his attending physician at that 
time removed a " stone " from the umbilicus. I apiplied a poultice, 
and awaited developments. The above condition continued from 
day to day, with the exception that the tumor projected more and 



644 DISEASES OF WOMEN. 

more from the umbilicus, and the circumscribed hardness decreased. 
Any movement of the body or handling of the tumor produced se- 
vere cutting pain in the part, The tumor was exquisitely tender. 
1*^0 constitutional symptoms accompanied the trouble. 

On the tenth day from my first visit I made an incision into the 
tumor for the purpose of exploration, about half an inch in depth, 
when I came upon a hard substance which, after considerable diffi- 
culty, I removed, and found to be a concretion, smooth and ovoid 
in shape, about the size of a medium hickory-nut, and of the color 
and appearance of a phosphatic calculus, with a strong urinous 
smell. After the removal the wound readily healed. The ordinary 
retraction of the tissues within the navel fossa took place, and the 
man has suffered no inconvenience since. 

"What was the concretion ? In the '' Medical Record," ^o. 354, 
Dr. Rose's article describing a patent urachus called this case to 
mind, and I have transcribed the above from my notes of the time. 

I can not conceive this concretion to have been anything else 
than a calculus formed from urinary deposit in a patent urachus. 

'No treatise within my reach mentions anything of the kind, and 
the novelty of the case is my reason for reporting it. 

In this man there was doubtless a similar calculus formation 
something more than twenty years before. 

Very Rare Form of Monstrosity of the Female Genito-TJrinary Or- 
gans (" Gazette des Kopitaux.") — In the words of M. Tillaux, at the 
Hospital Lariboisiere, there is at present a small, deformed woman, 
twenty-six years of age, who presents an exstrophy of the bladder, 
with complete absence of the vagina. The external organs of gen- 
eration are represented only by the orifice of the uterus, which is 
situated in the median line almost on a level with the skin, and by 
rudimentary labia minora and majora which are not united in front. 
The clitoris, urethra, and anterior wall of the bladder are absent. 
The ureters open into the rudimentary bladder near the median line. 
Palpation shows that the pubic bones are separated in front by a 
space that is about as wide as five fingers, and the pelvis seems to 
be enlarged to that extent. The umbilical cicatrix is located at the 
middle of the superior border of the exstrophic bladder. The cervix 
uteri forms a slight prominence into which the skin is attached. It 
is conical in form. The cavity of the uterus is of nearly the normal 
depth, but rectal examination shows that in shape the organ retains 
the peculiarities of childhood. The patient began to menstruate at 
the age of fifteen years, and since then has been perfectly regular. 

Operative Treatment of Ectopia Vesicae. (By Prof. Trendelen- 



MALFORMATIONS OF THE BLADDER AND URETHRA. 645 

burg, Bonn ; " Centralbl. f . Cliirurg.," 1885, JSTo. 49.)— Former meth- 
ods are criticised. Thiersch's flap-closure, e. g., does not secure use of 
the bladder musculature. Trendelenburg's first attempts to secure 
direct union of a vesical and urethral fisssure by joining its lateral 
edges were begnn five years ago. His plan is by dividing the sacro- 
iliac synchrondrosis on each side to mobilize the iliac flanges, and 
then hy lateral pressure to approximate them in front. Finally, the 
fissure thus narrowed is, after reposition of the bladder to be directly 
closed by freshening and suturing its edges. Inferiorily the union 
is to be continued at least to the beginning of the pars bulbosa ure- 
thrae. Division of the sacro-iliac symphysis is in children simple, 
and, when carefully done, not dangerous. The child is laid on its 
belly, and a finger introduced into the rectum to determine the po- 
sition of the incisura ischiadica major and superior gluteal artery. 
A long cut is then made over said symphysis ; this is gradually deep- 
ened until strong lateral pressure makes the pelvic flange yield. On 
account of the large pelvic vessels it is not permissible to cut through 
the deepest portion of the symphysis. Toward puberty and later in 
life this operation would have to be done with the chisel, and would 
be more serious. The construction of a continuously active com- 
pressing apparatus that could be tolerated for weeks proved difli- 
cult. Tourniquet arrangements were not borne. A girdle crossing 
in front, with extension weights of ten to flfteen pounds attached, 
has of late proved satisfactory. Where previously the spinge sup. 
ant. were seventeen centimetres apart, they approached to within 
eleven and a half centimetres. The two pubic symphysis stumps, 
formerly two inches apart, were now almost in contact. It is well 
to delay the operation for the fissure some six or eight weeks. This 
second operation begins with freshening the fissure borders ; he then 
frees the edges of the bladder somewhat, and unites with Lem- 
bert's sutures. The urethra has usually been inckided in the oper- 
ation. A catheter is left for a few days. In all cases as yet the 
union to the extent of urethra and bladder-neck has subsequently 
separated. In a two and a half year old boy the remainder of the 
bladder held and the prolapse was remedied. He thinks that by 
further perfecting his operation it may prove successful. 

Operation for Congenital Extroversion of the Bladder of an Infant 
Five Days old.— (By H. C. Wyman, M. D., Detroit, Michigan, " :N'ew 
York Medical Kecord," December 12, 1885). — From the umbilicus 
down to the triangular ligament there was a failure of development 
causing an extroversion of the posterior wall of the bladder, show- 
ing the orifices of the ureters and an absence of the dorsum of the 



e4:6 DISEASES OF WOMEK 

penis. Dribbling of urine from the ureters was constant. Under 
cliloroform incisions were made on either side through the integu- 
ment and superficial fascia just forward of the anterior superior 
spine of the ilium two inches upward, to secure relaxation ; the 
edges of the fissure were then pared and fastened together wdth 
harelip pins with iDtermediate sutures, and the wound dressed with 
oxide of zinc and absorbent cotton, a drainage-tube for the urine be- 
ing left in the wound. The penis was not touched, being reserved 
for a secondary operation. The recovery was rapid and perfect. 
The child died from convulsions two months later, before the opera- 
tion upon the penis could be performed. 



CHAPTEE XXXYI. 

FUNCTION OF THE BLADDER. 

The function of the bladder is to act as a reservoir for the urine, 
and at proper intervals to expel it through the urethra. The filling 
of the organ with urine is a comparatively slow and gradual process, 
the fluid entering it from the ureters drop by drop, or in a very 
SQiall stream. As it enlarges it does so in the direction of least re- 
sistance, viz., laterally and superiorly. The lateral being its long- 
est diameter, it enlarges first in that direction, until after a time a 
limit is set by the bony pelvic boundaries, when it rises from the 
pelvis somewhat, thus escaping from the pressure below. This 
movement of the bladder is facilitated by its serous surface gliding 
easily over that of the adjacent organs. 

The bladder receives its nervous supply partly from the mesen- 
teric ganglia of the sympathetic, and partly from the lumbar portion 
of the spinal cord : it has therefore nerve-filaments from both the 
cerebro-spinal and sympathetic systems. The sphincter vesicse is in 
health in a state of tonic contraction which results in retaining the 
urine in the bladder. This act is entirely involuntary and uncon- 
scious and is performed in a perfect manner both during the waking 
and sleeping hours. When it is desired to evacuate the bladder this 
sphincter is relaxed by an act of the will conveyed through the 
cerebro-spinal fibers, but this relaxation once accomplished, the 
further act by which the organ is emptied is performed without the 
intervention of the will. The experiments of Kupressow demon- 
strate conclusively that the nervous center which presides over con- 
traction and relaxation of the sphincter vesica is located in the lum- 
bar region of the spinal cord. And it may be accepted that with 
other functions of a protective nature the spinal cord maintains the 
normal action of the urinary organ. 

There has been considerable discussion among different authors 
as to whether closure of the vesical urethral orifice is a voluntaiy or 



648 DISEASES OF WOMEN. 

an involuntary act. Witte and Rosenthal maintain that the closure 
is due to " tonicity from nerve force," which resists the urine press- 
ure. Kupressow holds the same view, basing his opinion on a se- 
ries of experiments which he made, and further maintains that the 
sphincter vesicse is at the neck of the bladder to eject the urine 
completely out of the urethra, in place of standing guard and hold- 
ing the vesical outlet closed. By others it is claimed that this 
musculo-elastic ring hinders the entrance of urine into the urethra, 
but that the tension of the bladder- walls when the organ is filled 
overbalances this elasticity, and a drop of urine escaping into the 
urethra brings the necessity for urination to the senses, and the act 
then becomes a voluntary one. 

It has been found, however, in cases of urethro-cystic vaginal fist- 
ula, where the upper part of the urethra and neck of the bladder 
were totally destroyed, that, after the healing of the parts, the an- 
terior or lower end of the urethra was practically able to control the 
urine. 

The act of emptying the bladder is a very important and inter- 
esting process, and is not so simple as might at first be imagined. 
As the organ has three openings and is emptied by the concentric 
contraction of its muscular coat, the urine is not only expelled 
through the urethra, but there is a tendency to regurgitation or 
backward pressure of the fluid into the ureters. The backward 
flow is effectually prevented by a very complete and interesting ar- 
rangement. The protection is threefold : First, by the oblique direc- 
tion that the ureters take in piercing the vesical wall ; second, by the 
two muscular slips already mentioned, that pass from the sphincter 
vesicge to the insertions of the ureters. As the bladder gradually 
fills these slips are tightly drawn, and thus partially or wholly close 
the ureteric orifices. Moreover, it may be presumed that as these 
muscular fasciculi have their origin in the vesical neck, they act 
most vigorously during urination, when the bladder pressure tends 
to cause regurgitation into the ureters. Their greatest use is, in all 
probability, during the act of micturition. This view is borne out 
by the fact that these little muscles are in a rudimentary condition 
in the female, the urethra being shorter and the force necessary to 
empty the bladder much less than in the male ; and further, by the 
well-known fact that when the hypertrophy of the muscular walls 
of the female bladder does occur, these fasciculi are proportionately 
enlarged. Third, by a ligamentous band, not described in the text- 
books of anatomy, which runs from one ureteric opening to the 
other, inclosing their vesical ends, and is known as the inter-ureteric 



ruNCTio:^' or the bladder. 649 

ligament. Its mode of action is this : as the bladder gradually 
fills, the openings of the ureters are carried farther apart, and with 
them the ends of the ligament. Being elastic it yields to a certain 
extent, and after a time, being able to yield no more, pulls upon 
both openings, closing them more or less completely. During urin- 
ation the tension of the ligament gradually decreases, and then the 
muscular fasciculi and the oblique direction in which the ureters 
enter the bladder come into play, the ligament being of use only 
during filling and distention. 

If from any cause the bladder is not emptied at the proper time, 
the organ is not only injured by o\^erdistention, but more serious 
results may follow if the retention continues for some time ; although 
the bladder is too full to receive any more urine, the kidneys con- 
tinue to secrete until not only the bladder, but also the ureters, 
renal pelves, and kidney-tubes become overfilled. When the press- 
ure on the urinary side of the Malpighian tuft equals that of the 
blood-stream in the glomerulus, secretion of urine at once ceases, and 
we have a mechanical suppression. After death the bladder, ureters, 
and renal pelves are found to be greatly distended, and the kidney 
pale, of a bluish, pearly color in the cortex, and oozing urine from 
the cut surface. 

Maas and Punier (" ]^ew York Medical Record," October 1, 1881) 
have performed experiments on animals and men which demon- 
strate to their satisfaction that the bladder, whether healthy or dis- 
eased, as well as the urethra, possesses the faculty of absorption in a 
greater or less degree, varying with the substance used. Their 
methods when experimenting on animals were as follows : The 
bladder was fully exposed, both ureters tied about half an inch 
above their termination, then divided above the ligatures, and the 
urine conducted outside of the body by means of glass cannulge in- 
troduced into the central ends. The bladder was then evacuated by 
a catheter through which the solution experimented with was in- 
jected, the catheter withdrawn, and a ligature drawn tightly around 
the urethra between the prostate gland and the neck of the bladder ; 
sometimes after tying the ureters and urethra the bladder was emp- 
tied by a Pravaz syringe, the medicated solution injected through 
the cannula of the latter and the puncture closed by ligature. 

In a second series of experiments the abdominal cavity was not 
opened, but after drawing off the urine the solution was injected 
through the catheter, and the mouth of the latter plugged. The 
substances used were ferrocyanide of potassium, salicylate of soda, 
cyanide of potassium, strychnine, atropine, curare, apomorphia, and 



650 DISEASES OF WOMEK 

pilocarpin. All of these substances were absorbed, but some so 
slowly that their physiological action was not manifested ; thus atro- 
pine seemed to have no effect upon the animal, but a small quantity 
of its urine collected during the continuance of the experiment and 
instilled into the eye of another animal rapidly caused dilatation of 
the pupil. The diseased bladder was also found capable of absorb- 
ing the same substances. 

In their experiments on man, Maas and Punier used iodide of 
potassium and pilocarpin. As regards the excretion of the former, 
they call attention to the fact that in some individuals it rapidly 
passes off by the urine, in others by the saliva, and in others by only 
one of these paths to the exclusion of the other. The method used 
was the following : Taking only individuals with healthy bladders, 
the latter were evacuated by a INelaton catheter, after which in 
twenty-eight cases they injected fifty grammes of a ten-per-cent so- 
lution of iodide of potassium, following this up in thirteen other 
cases with an injection of one or two centigrammes of muriate of 
pilocarpin haK an hour later. The iodide was detected in the saliva 
in iifty-seven per cent of the first, and seventy-seven per cent of 
the second series, but usually in small quantities only. The dis- 
eased bladder was found to absorb much more promptly ; iodide of 
potassium was detected in the saliva when only 2*0 were used. A 
solution of 0*4 morphine in 2*0 of distilled water used in this way, 
acted very plainly as an anodyne. Pilocarpin made up into a bougie 
with cocoa-butter, and introduced into the urethra (both healthy and 
diseased), manifested its specific effects. 

L. Schafer found that after producing vesico-vaginal fistulse in 
animals there was increase of from two to three per cent, and some- 
times from four to five per cent, in the amount of urine passed over 
that passed before the fistulas were made ; and he feels convinced 
that under normal conditions of urinary secretion the amount of 
urine in the bladder is gradually diminished by a slight though reg- 
ular absorption of its watery elements. If this be true, we may 
look to a too rapid absorption as one of the causes of gravel and 
urinary calculi. 

On the other hand, however, Susini found that after injecting 
potassium iodide and belladonna into his own bladder, and retaining 
them for many hours, no trace of the former was found in the saliva, 
and no appearance of the specific action of the latter was made man- 
ifest. Ailing agrees with Susini, and the experiments of P. Dubelt 
also support this view. After careful consideration of the evidence 
]pro and con^ I am strongly inclined to the view that the bladder 



FUNCTION OF THE BLADDER. 651 

does not absorb anjtliing, save possibly a little water, unless its 
epithelial surface is displaced or destroyed. When abrasion does 
occur, absorption is rapid and its effects marked. The fact that the 
mucous membrane of the bladder is able to absorb liquids after ero- 
sion of its epithelium throws much light on the cause of some of 
those peculiar constitutional symptoms accompanying chronic cysti- 
tis, and known by some authors as ammonsemia. 

The inner surface of the bladder is lubricated by a very thin se- 
cretion of mucus. This can be demonstrated by putting some fresh, 
normal urine in a clean bottle. In a short time a slight hazy cloud 
will settle to the bottom. When examined microscopically it will 
be found to consist of a few epithelial scales and mucous fibrillse — 
long, fine, and often interlacing. In disease this secretion becomes 
greatly increased, and is then thick, viscid, and ropy. The normal 
secretion when tested chemically is found to contain an abundance 
of the earthy and alkaline phosphates. 

A healthy woman urinates from four to six times in every twen- 
ty-four hours, and passes in all from thirty-five to sixty ounces of 
urine, the average being about forty-five ounces. The amount 
passed varies much with the season of the year, more being passed 
in winter than in summer ; it varies also with the amount of fluid 
ingesta, rest, and exercise. Neither limpid nor concentrated urine 
are well borne by the bladder. 

The pressure of the urine in the bladder being of importance in 
both health and disease, I deem it advisable to give here the results 
of some experiments by Schatz, Odelbrecht, Ilegar, and Dubois. 
These experiments were made with the manometer, an instrument 
which by means of a column of mercury may be adapted to regis- 
ter the exact pressure in the bladder. 

They found the pressure to be from twelve to sixteen inches 
while standing, in the recumbent posture it was only from four to 
six inches. The pressure in the recumbent position Dubois be- 
lieved to be due not to visceral pressure from above, but to the nat- 
ural tonicity of the distended organ ; for in the cadaver, after re- 
moving the other viscera, the pressure in the bladder indicated four 
inches, plainly due to the elasticity of the organ itself. The same 
has been observed in cystocele, in which the visceral pressm-e is also 
absent. 

The pressure is about the same in both sexes, and at all ages. It 

was found to rise from one half to one inch with each inspiration, 

and to fall about the same with each expiration. In laughing, 

coughing, etc., it rose as high as from twenty to sixty inches. In 

43 



652 DISEASES OF WOMEK 

diseases of the spinal cord, such as myelitis, and after injuries to 
the vertebrae, Dubois found a marked decrease in bladder pressure. 
These curious observations on the varying degrees of pressure 
arising from change of posture are not without value. They help 
one to understand why, in some diseases of the bladder, patients 
should maintain the recumbent position. 



CHAPTEE XXXYII. 

FUNCTIONAL DISEASES OF THE BLADDEE. 

It has been the rule among pathologists to class under the head 
of functional diseases all those in which no lesion of structure was 
discoverable in the organs concerned. Although we are still obliged 
to accept this nomenclature, the progress of pathological knowledge 
in the past few years has weeded out many of the so-called functional 
affections : and as this knowledge advances, and new and efficient 
means for observation and study arise, we shall be able to root out 
many more, thus doing away with much of the vagueness and uncer- 
tainty in which this class of affections is shrouded. But even with 
the improved facilities for diagnosis at om* command, there are still 
many diseases in this list. Owing to the obscurity at present sur- 
rounding the subject of reflex or sympathetic disorders, i. e., the 
abnormal condition of an organ or organs, near or distant, affecting 
the function or nutrition of another organ, we are obliged to put 
these affections in this class also. Under this head then will be 
considered : 

I. Derangements of function in which there is no recognizable 
organic lesion. 

II. Derangements of function due to diseases of the nutritive 
and nervous systems, and to abnormal conditions of the urine re- 
sulting therefrom. 

III. Derangements of function due to inflammatory and other 
affections of the pelvic organs, such as metritis and pelvic perito- 
tonitis. 

It will be observed that in this arrangement of the subject, al- 
though a number of structural diseases are considered, they all 
stand in a causative relation to the disturbed action of the bladder, 
the latter being free from any organic lesion, and only disturbed in 
the discharge of its duty by influences outside of itself. 

Before discussing these functional disorders in detail, it will be 



654 DISEASES OF WOME!^. 

necessary to fix clearly in the mind their various manifestations ; 
these are : frequent urination, or polyuria ; difiicnlt urination and re- 
tention, or ischuria ; painful urination, or dysuria ; pain after urina- 
tion, or vesical tenesmus ; and incontinence of urine, or enuresis. 
These deranged actions may also be due to organic diseases of the 
bladder, but they will at present only be discussed in connection 
with the three classes of functional derangements of that organ just 
referred to : 

1. Derangements of function in which there is no recognized 
organic lesion. There are -Q.ve of these derangements which demand 
special consideration. 

3. l^euroses, pure and simple. 

2. Derangements due to hysteria. 

3. Derangements due to disorders of the sexual function. 

4. Derangements due to malaria. 

5. Derangements due to ovarian affections. 

1. Neuroses. — By this term I refer to purely nervous affections 
of this organ. They are rather rare, it is true, but that they do ex- 
ist there is no doubt, for there are certain conditions that seem to 
depend on no other known pathological cause. 

We learn from the books that vesical neuralgia is of this class. 
It is known by a variety of names, each taking as its key-note some 
peculiar manifestation or symptom, as irritable bladder, cystospasm, 
cystoplegia, and neuralgia vesicsB. 

The term irritability so commonly used in speaking of the 
healthy organ must not be confounded with the condition known as 
irritable bladder. The former refers to a certain property that the 
viscus possesses, by means of which it is able to respond to certain 
stimuh, while the latter refers to an abnormal condition of sensation, 
viz., super-sensibility, or hyperaesthesia. 

2. Derangements due to Hysteria. — Hysteria holds a prominent 
place among the causes of functional derangement of the bladder, 
the vesical affection being probably only a fragment of a general 
neurosis. Acute and chronic diseases of the brain and spinal cord 
also produce various vesical difficulties of this nature, but these will 
be discussed under another class. Any one who has suffered the 
mortification of an involuntary evacuation of urine from fear, will 
understand how the brain and nervous system can influence the 
bladder. 

In the variety of conditions grouped under the head of hystena, 
it is often observed that frequent urination is a prominent symptom. 
The cause, in many cases, is the peculiar character of the urine se- 



FUNCTIONAL DISEASES OF THE BLADDER. 655 

ereted in this disturbed condition of the nervous system. The lim- 
pid urine of hysterical patients is deficient in solids, the watery por- 
tion being greatly in excess. This unnatural composition renders 
the urine irritating to the bladder so that it can not be long retained. 
The quantity of urine secreted is, at certain times, excessive, which, 
together with its irritating quahty, renders urination necessarily 
very frequent. 

But apart from the frequent urination which occurs in severe 
attacks of hysteria due to the conditions just mentioned, cases are 
often seen of frequent micturition which can only be accounted for 
by the state of the nerves which govern the action of the bladder. 
When the quantity and composition of the urine are normal, and the 
patient can retain it without pain or distress during the night, but 
has to pass it every hour or two during the day, it may safely be 
presumed that the trouble is functional, and due to a disordered 
state of the nervous system. The only condition which resembles 
this history is occasionally seen in prolapsus uteri, the patient being 
free from trouble while reclining, but having to urinate frequently 
when in the erect position. 

Hysterical patients frequently suffer from retention of urine. 
Some of them complain for a time of difficulty in emptying the 
bladder, and finally fail to do so altogether. At other times they 
suddenly find that they can not urinate. There are conflicting 
views regarding the cause of this retention, some believing that such 
patients can not urinate, and others that they will not. Those who 
believe that the trouble is feigned and not real, do so on the ground 
that in this morbid state of the nervous system the patients enjoy 
catheterization, which would be distressing to any one of healthy 
mind and body. Others claim that in the extreme sexual excite- 
ment which occurs in some cases of hysteria, the chronic erection 
of the clitoris makes pressure upon the urethra, and prevents the 
flow of the urine through the canal which is at that time com- 
pressed. 

I am satisfied that both kinds of cases occur. There are those 
who complain of retention when they know that the doctor will use 
the catheter, but they can urinate easily when they please. Others 
I have seen who were suffering from excessive and painful disten- 
tion of the bladder and would have gladly relieved themselves if 
they could. 

3. Derangements due to Disorders of the Sexual Function. — An- 
other class which resembles the hysterical patients in the frequency 
of urination, but differs in every other respect, is found in those 



656 DISEASES OF WOMEN. 

who suffer from the habit of masturbation. The constant conges- 
tion and irritability of tlie pelvic organs, caused and kept up by the 
unnatural and excessive exercise of the sexual function give rise to 
frequent urination. Such patients complain of general weakness, 
which is not accounted for bj any organic disease of the general 
system. Nor is there disease of the bladder ; it is simply enfeebled 
and irritable like the rest of the pelvic organs. To make a correct 
and positive diagnosis in such cases is by no means easy, because it ne- 
cessitates our detecting the habit of masturbation, and this is usually 
one of the most difficult tasks for the diagnostician. It is not al- 
ways prudent to question the patient regarding the habit ; and even 
when that is done they frequently fail to comprehend the question, 
or they answer falsely in the negative. The physician is thus gen- 
erally left to guess at the truth of the matter. 

The s}Tiiptoms developed by masiurbation are depression of the 
nervous system, manifested by lassitude, sadness, or emotional ex- 
pressions of joy and sorrow, those affected with this habit being easily 
affected to smiles or tears. The eyes are dreamy and heavy, and the 
pupils dilated. Such subjects are excitable, irritable, and easily ex- 
hausted. They often have headaches. Nutrition is apparently good 
in some cases, as is shown by the fair supply of flesh ; still, they often 
suffer from acute indigestion, although at times the appetite is re- 
markably good. The bowels are usually constipated, and the mus- 
cles soft and flabby. The exhalations from the skin are some- 
times changed, so that a peculiar odor is noticeable about such persons- 
This odor can not be described, but, when once recognized, is easily 
remembered. 

In this variety of functional derangement of the bladder, as well 
as in all the other varieties of neurotic affections, the symptoms vary 
in severity to a great extent in the same individual. The trouble is 
by no means regular and constant in its manifestations, as in organic 
diseases. Whatever disturbs the nervous system will increase the 
disorder. The rule is that frequent urination is the prominent symp- 
tom, but occasionally painful micturition is complained of. It is 
then simply a slight scalding pain, experienced when the urine is 
passing over the irritable or chafed mucous membrane about the 
meatus urinarius. 

4. Derangements due to Malaria. — Another cause which I believe 
acts through the nervous system is malaria. The effect of malarial 
poison on the bladder and urethra is very peculiar. The trouble 
produced in this way has been called urethral fever, and is described 
as an inflammation of the mucous membrane of that canal. It might 



I 



FUNCTIONAL DISEASES OF THE BLADDER. 657 

more properly be called malarial fever of the urethra. As I have 
observed this affection, the bladder and urethra are usually both 
affected, but I do not consider the disease one of a well-dehned in- 
flammatory character. There are usually symptoms of malaria pres- 
ent, but not necessarily chill and fever. On the contrary, I believe 
that I have observed the affection more frequently in remittent than 
in intermittent fever, and very often, where the constitutional symp- 
toms were not more than a shght derangement of the digestive 
organs, with moderate elevation of temperature in the after-part of 
the day. 

The symptoms vary, but usually are as follows : The patient com- 
plains of frequent desire to urinate, and some vesical tenesmus ; se- 
vere burning pain on passing water, with stinging and burning in 
the uretlira after urination. The history of such cases resembles 
acute gonorrhoeal urethritis so far as the abruptness of the attack and 
the tenderness and pain of the urethra are concerned, but there is 
usually no discharge, or, at least, very little. In many cases the 
suffering is greatest in the afternoon and early part of the night. 
Under proper treatment the disease disappears as promptly as it 
comes on. 

6. Derangements due to Ovarian Affections. — In disease of the 
ovaries we sometimes find that the bladder suffers very much from 
deranged nerve action. The clearest and best account of this form 
of functional bladder trouble is given by Fothergill in his paper on 
" Ovarian Dyspepsia," published in the " American Journal of Ob- 
stetrics," January, 1878. In speaking of the derangement of the 
stomach and pelvic organs, he says : *' It soon became clear that there 
was some condition existing which stood in a causative relation to 
both the dyspepsia and the uterine disturbance. That condition was 
quickly seen to be a state of vascular excitement in one or both ova- 
ries, usually the left ovary. This condition Barnes terms ' oophoria.' 
In this state there is always more or less pain constantly in the iliac 
fossa, more rarely on the right, much aggravated at the catamenial 
periods, when the pain shoots from the turgid ovary dowm the thigh 
of the corresponding side along the genito-crural nerve. This pain- 
ful state is otherwise known as 'ovarian dysmenorrhoea.' When 
pressure is made over this tender ovary during the catamenial flow, 
acute pain is experienced. Pressure also elicits pain during the inter- 
menstrual interval. At the sanae time that acute pain is felt, evi- 
dence is furnished of emotional psrturbation ; the patient feels as if 
about to faint, or ' feels queer all over,' as some express it, and the 
changes in the patient's countenance speak of something more than 



658 DISEASES OF WOMEN. 

more pain, pure and simple. It is evident there is a wave of nerve- 
perturbation set up, which excites more than the sensation of pain. 
Commonly the patient feels sick after the momentary pressure, and 
asks to be permitted to sit down, alleging that she feels sick and 
faint. If a careful physical examination be made, it will be found 
that there is an enlarged and tender ovary, which may sometimes be 
caught betwixt the linger in the vagina and the lingers of the other 
hand applied to the abdominal wall of the ovary. Such manipula- 
tion elicits manifestations of acute suffering from the patient. Fre- 
quently the rectus muscle over the tender ovary is hard and rigid, 
80 as to place the organ as perfectly at rest as is possible ; just as we 
see the rectus to stiffen and become rigid over the liver when there 
is an hepatic abscess, and thus to secure rest, as regards movement, 
for that viscus. ... 

*' 'Not rarely, too, there is set up a very distressing condition, viz., 
that of recurring orgasm. This occurs most commonly during sleep 
— ' the period par excellence of reflex excitability.' In more aggra- 
vated cases it also occurs during the waking moments, and this it 
does without any reference to psychical conditions. 

" The centers of the pelvic viscera lie near together in the cord, 
and the condition of one is readily communicated to another. The 
brief recurrent orgasm affects the bladder-centers, and the call to 
make water is sudden and imperative, and must be attended to at 
once, or a certain penalty be paid for non-attention. This last is not 
a common condition, fortunately, but it is a source of great suffering, 
bodily and mental, when it does occur. The condition of the ovary 
also acts reflexly upon the uterus, and keeps it in a state of persistent 
erection and high vascularity, with the normal phenomena attendant 
thereupon." 

It is evident that this form of bladder trouble can only be re- 
lieved by treatment of the ovarian disease, for which bromide of 
potassium and counter-irritation are very serviceable, with, of course, 
attention to the general health. 

Symjptomatology. — In all of these nervous affections of the urin- 
ary organs, pain and a feeling of weight and uneasiness in the region 
of the bladder are usually present. Still, the most constant and dis- 
tressing symptom is the frequent and painful desire to micturate, 
which the patient tries to relieve by frequent urination, a few drops 
only being passed at a time. Of course, there are varying grades of 
this affection, in some of which these symptoms are by no means so 
troublesome. In some extreme cases, when a little urine collects in 
the bladder, the pain and irritability are so intense that it is spurted 



FUNCTIONAL DISEASES OF THE BLADDER. 659 

out by a very forcible and painful contraction of the organ. The 
sense of weight and bearing down are most intense in the upright 
position. Tlie pains may be confined to the neck or base of the 
bladder, or they may shoot in all directions. The pain in micturition 
may be present at the beginning, but is usually most severe during 
and after the completion of the act. 

The local pain and distress, with the frequent urination and un- 
rest, react upon the general nervous system, thereby greatly aggra- 
vating the original disorder. This lowered systemic condition in 
turn affects the local disorder, and so the one is continually aggra- 
vating the other. In this way the patient, if not relieved, goes on 
from bad to worse, until the host of phenomena characteristic of 
nervous prostration and general ill-health are developed. 

In certain cases the sufferers are by no means so badly circum- 
stanced, but time and neglect tend to produce these results sooner 
or later. In some cases, again, the suffering gradually disappears, 
and the patient is restored to health without much aid from treat- 
ment. The trouble appears to wear itself out. 

Diagnosis. — The symptoms I have given are by no means pathog- 
nomonic of these affections, the same being produced by organic 
disease of the bladder, calculi, and various other causes. The diag- 
nosis must be made by exclusion. The first thing to do is to make 
a careful microscopical and chemical analysis of the urine. J^ot only 
can local organic trouble be thus eliminated, but important knowl- 
edge as to the state of the general system obtained. 

If no urinary abnormality is discovered, a careful external and 
internal examination of the organ itself should be made. A finger 
should first be passed into the vagina, and an endeavor made to ascer- 
tain, by pressure on the vesico-vaginal septum, whether there is any 
abnormal sensitiveness of the vesical base or neck, or of both. Then 
the sensibility of the mucous membrane should be tested by the in- 
troduction of a sound. 

If sufficient cause be not found in either the urine or the bladder, 
the case may be set down as one of pure neurosis, to be treated as I 
shall hereafter describe. Systemic conditions, such as hysteria or 
chlorosis, should be considered, as they point to a tendency to neu- 
rotic difficulties, liable to be localized. 

Prognosis. — As a rule, the prognosis is favorable. This, how- 
ever, is not always the case. The longer the affection has lasted, the 
more difficult it is to cure. Most cases may be cured in a few weeks' 
time, and even the most obstinate in a few months. The danger to 
the patient lies in the fact that continuance of the disorder is liable 



660 DISEASES OF WOMEK 

to bring on an organic lesion, and, whether this results or not, the 
reaction on the general system tends, in the worst cases, to produce 
hypochondriasis or even melancholia. 

Causation. — These nervous affections of the bladder occur most 
frequently in those of the nervous temperament. A highly devel- 
oped nervous system predisposes one to nervous affections of all 
kinds. Especially is this the case if the subject is not well sustained 
by a vigorous nutritive system. Those in whom the emotional ele- 
ments predominate in the mental composition are more liable to 
nervous affections of the bladder than those of the more intellectual 

type. 

The exciting causes include all influences which depress or ex- 
haust the nervous system. Mental taxation or excitement which 
tends to increase the excitability of the nervous system may derange 
the function of the bladder. Constitutional diseases which lower the 
tone of the whole organization also tend to produce the affections 
now under discussion. ^ 

It is not possible to give any satisfactory explanation of the reason 
why the innervation of the bladder becomes deranged in some per- 
sons from causes which are in others inoperative. It may be that 
those who are most susceptible to this cause are so because of some 
inherited sensitiveness of the pelvic organs which responds to the 
disturbing influences. This appears to be the case with those who 
suffer from irritation of the bladder caused by ovarian disease. This 
is apparent from the fact that one affected with disease of the ovaries 
will suffer from derangement of the function of the stomach, while 
another having a similar ovarian affection will suffer most from fre- 
quent urination. 

Regarding the causative relations of malaria to irritation of the 
bladder, all that can be said at the present time is that this materies 
rnorhi appears to act upon that viscus through the nervous system. 

Treatment — This may be classed as general and local. In pure 
neuroses, attention should be first directed to improving the general 
condition of the patient. Cheerful company should be provided at 
meals and at other times, and there should be exercise suited to the 
strength of the patient, daily ablution, and proper regulation of diet. 
This latter should be simple and nourishing, and of a kind calculated 
to produce as little urea and urinary solids as possible. In cases 
where the urine is limpid, the opposite course is to be pursued. 
Pastry, irritating condiments, and stimulants, except in rare cases, 
should be prohibited. The exception to this is where a condition 
of the system calling for stimulation exists. In such cases the irrita- 



FUNCTIONAL DISEASES OF THE BLADDER. 661 

tion of the bladder produced by their use may be more than counter- 
balanced by the good they do the general system. Tea is better than 
coffee, but neither is to be used in any great quantity. 

The condition of the urinary secretion must be carefully watched, 
and any abnormality quickly and judiciously corrected. Where there 
is any tendency to excessive acidity, the effervescing waters, rich in 
carbonic-acid gas, will be found of use. 

The bowels should be kept moderately well open, but should 
never be irritated with active cathartic agents. 

Tonics and medicinal stimulants are often of great value when 
judiciously exhibited. Strychnia in very small doses does not, as 
might be supposed, aggravate the irritable condition of these organs. 
The nerve-tone being below par, strychnia, by gradually increasing 
it, is of great service. In large doses it is undoubtedly hurtful, and 
should never be long continued. Quinine, iron, and the various sim- 
ple and compound vegetable bitters act well in the cases where their 
exhibition is indicated. 

If the irritation is extreme, various soothing emulsions and de- 
coctions may be given by the mouth. Of these, preparations of 
marshmallow, triticum repens, acacia, pareira brava, and buchu act 
well. Emulsio-amygdalee is much used and highly recommended by 
the German authors. 

Some objections have been raised to the use of these drugs on 
the score that they increase the flow of urine, thus aggravating the 
local irritability. The fact is, however, that the presence of fairly 
normal urine in the bladder in moderate quantity seems to relieve 
rather than increase its irritable condition. 

The local treatment may be as follows : A cupful of warm hop- 
tea, containing from twenty to forty drops of laudanum, may be 
injected into the rectum. Suppositories containing opium may often 
be used with benefit. With the opium or morphine in the supposi- 
tories may be combined belladonna, atropine, or hyoscyamus. Mor- 
phine in the form of Magendie's solution may be injected directly 
into the bladder. There seems to be no especial advantage in this 
mode of administering anodynes, hypodermic injections of the drug 
acting as well, if not better. Emulsions, decoctions, and infusions 
of cannabis Indica, hyoscyamus, belladonna, and other like drugs 
may be used by the mouth, as the case may require. 

Grood effects have followed the use of rectal injections containing 
chloral hydrate (grains 15 to water §i or Jij). It may also be given 
by the mouth, but does not usually act so quickly or have such a 
direct local effect. 



662 DISEASES OF WOMEN. 

The injection into the bladder of a sohition containing morphine, 
followed bj canterization of the mucous membrane, is highly spoken 
of by Braxton Hicks. He claims in this way to deaden the reflex 
irritability of the membrane. 

I must insist on this — that opium shall be used in such cases with 
great care, and never continued long. If this rule is neglected, it 
will lead many nervous patients to contract the opium habit, which 
disease is worse than irritable bladder. 

Debout recommends the use of bromide of potassium by the 
mouth, and also in suppository, combining with it in the latter tinct- 
ure of opium and belladonna. I prefer hydrobromic acid to the 
bromide of potassium. 

When the trouble is due to masturbation, moral and mental in- 
fluences must be brought to bear, as well as medication and regula- 
tion of diet and habits. In these cases the bromides will be of serv- 
ice. 

If all other treatment fails to accomplish the desired result, resort 
should be had to mechanical means, viz., the rapid and forcible dila- 
tation of the urethra. Some authors, indeed, think so highly of this 
method that they boldly assert that time spent in medication is time 
lost. Astonishing and very gratifying results have certainly followed 
its use in a number of cases. Hewetson reports in the "Lancet" 
(page 4, vol. xii, 1875) that in this manner he cured a case of cysto- 
spasm of iifteen years' duration. This procedure is spoken of in the 
highest terms by Teale ("Lancet," page 27, vol. xi, 1875), as also by 
Spiegleberg, Tillaux, and others. In the cases where this treatment 
gives relief, I believe that there is some inflammatory condition 
present, or at least something more than a neurosis. 

When due to malaria, the treatment is usually simple and satis- 
factory. Quinine in full doses, as recommended by Bricheleau 
(" Arch. gen. de med."), for one day, and then in small doses before 
meals for a week, will usually cut the trouble short, and prevent its 
return. The digestive organs require attention when they are out 
of order, as they usually are. 

If due to hysteria, the original disease should be treated, not, 
however, neglecting the local trouble. When accompanying acute 
or chronic systemic diseases, it is only relieved when the original 
disease is cured, although in the mean time the annoyance may be 
greatly alleviated by the treatment already recommended. 



FUNCTIONAL DISEASES OF THE BLADDER. 663 



n.LUSTEATIVE CASES OF FUNCTIONAL DISEASES OF THE BLADDEK, IN 
WHICH THEKE IS NO RECOGNIZABLE ORGANIC LESION. 

Neuralgia of the Urethra and Heck of the Bladder. — A married 
ladj, who had never been pregnant, was tirst seen when she was 
twenty-six years of age ; she had then been three years married. She 
was well developed, and, although of a marked nervous tempera- 
ment, had always enjoyed good health. From puberty onward she 
had suffered pain at her menstrual periods, but not of severe charac- 
ter. When she was twenty-four years old she was chilled while rid- 
ing a long distance on a cold day, which was followed by frequent 
and painful urination. This was somewhat relieved by rest and 
diuretics. From that time she was subject to violent attacks of spas- 
modic pain in the urethra and bladder. The pain was of a sharp, 
lancinating character, generally coming on before and after her men- 
strual period ; it was, however, brought on at any time by nervous 
excitement or great fatigue. During the pain there was some diffi- 
culty in urinating, but the pain was neither relieved nor increased 
by the act. The duration of the pain varied, but usually did not last 
more than twenty-four hours. At times she became almost frantic, 
so great was the suffering. Large doses of opium would relieve her, 
but, as it caused very distressing after-effects, she avoided taking it, 
except when the attacks were exceptionally severe and prolonged. 
When she first came under my care she had a flexion of the uterus, 
with slight general tenderness of the pelvic organs, which accounted 
for her mild dysmenorrhoea, and I presumed that that might be the 
cause of the neuralgic pains in the bladder and urethra. She was 
treated for the uterine affection, and obtained complete relief from 
the painful menstruation and tenderness of the pelvic organs gener- 
ally, but no relief was obtained from the periodic attacks of pain 
in the urethra and bladder. She acknowledged that it was not quite 
so severe at her menstrual periods, but was " bad enough in all con- 
science," as she expressed it. 

Careful and repeated examinations of the urine were made when 
she had pain, and when she was free from it, but no trace of any 
renal, vesical, or urethral disease was obtained. The urethra and 
neck of the bladder were examined with the endoscope several times, 
but were found to be normal. Suspecting that the neuralgic pain — 
for such it apparently was — might be due to malaria, she was given 
fifteen grains of quinine within a period of eight hours, followed 
by Fowler's solution of arsenic in doses of three minims after each 
meal. The arsenic treatment was continued for several weeks, and 



664: DISEASES OE WOMEN". 

gave her some relief, the attacks being less violent, but still she 
suffered greatly. 

Moderate dilatation of the urethra was then practiced. This ag- 
gravated the trouble. Several different remedial agents, including 
opium, hot water, aconite, infusion of hops and belladonna, were in- 
jected into the bladder, but none of them gave any relief. The 
citrate of iron and quinia in five-grain-doses was then prescribed to 
be taken before meals, and Parrish's compound sirup of the phos- 
phates in drachm doses to be taken after meals. When the pain 
came on she was directed to take every three hours a drachm of 
camphor- water containing eight grains of muriate of ammonia, and 
to use a vaginal douche of hot water. This treatment usually re- 
sulted in mitigating the pain, but did not completely abolish it. 
Thirty minims of the compound spirits of ether and live minims of 
the tincture of cannabis Indica every four hours were substituted for 
the camphor- water and muriate of ammonia and with good effect. 
Under this treatment her attacks were far less frequent, and the re- 
lief from pain was prompt. She was so much pleased with her im- 
provement that she took a trip through the West and returned 
quite well, and has remained so for the past eight years. More re- 
cently I have had a case which resembled this one in many respects, 
particularly as regards the character of the pain and its causation, 
in which a four-per-cent solution of muriate of cocaine instilled into 
the urethra and bladder gave relief. 

A Peculiar Form of Neuralgia not yet described, excited by a 
Desire to Pass "Water and by Micturition. (By Dr. Putegnat, of 
Luneville. (Gaz. Hebdom de med. et chirurg., April 15, 186i.) — 
The following two cases, out of six published by the author, will 
give an idea of this peculiar neuralgia, W'hich consists on the one 
hand, in a special sensation in the bladder, and on the other, in 
symptoms of a neurosis of the ulnar nerve. 

M. X., aged fifty, with chestnut hair, of a nervous and san- 
guine temperament, very abstemious, in affluent circumstances, lead- 
ing a very active life, occupying very healthy apartments, free from 
all diathesis, except a slight rheumatic affection, liable to coryza in 
cold, damp weather, has never had any other nervous complaint be- 
yond headache and occasional gastralgia after eating dressed salads 
or raw fruit. 

From time to time, at varying intervals of weeks, months, and 
even years, without any apparent physical or moral cause, in all 
electric, barometric, and thermometric conditions of the atmosphere, 
as soon as his bladder is full, and he has a strong desire to pass 



FUNCTIOISrAL DISEASES OF THE BLADDER. 665 

water, he feels along the urinary passages, especially in the perinseum 
a peculiar sensation of numbness, not very painful, but acute, burn- 
ing, lancinating, and unpleasant from the accompanjnng sense of 
prostration. This strange sensation next affects the shoulders, 
comes down both arms, along the course of the ulnar nerve only, 
and gives rise in the forearm, the little and the ring lingers, to the 
same sensation as when the ulnar nerve is strongly compressed at 
the elbow. The pain is more acute on the left than on the right 
side, lasts about twenty or thirty seconds, and after diminishing 
gradually, disappears without leaving any trace behind it. 

M. X., of Luneville ; living in healthy rooms ; very active, 
easily moved and excited ; subject to headaches and to rheumatic 
pains ; free from any diathesis ; very abstemious ; complains, for 
several successive days, but at irregular intervals, and without any 
known cause, of a strange sensation along the outer border of the 
left forearm, on the inner side of the thumb, and the outer surface 
of the index-finger especially. This sensation he compares to the 
one produced in the last two fingers of the hand by compression of 
the ulnar nerve at the elbow. 

The painful sensation only comes on whenever he has a strong 
desire to pass water, persists during micturition, and ceases com- 
pletely immediately afterward. 

On analyzing the six cases of the author, we find four of them 
to have occurred in females. The mean age of the patients is forty- 
six; the oldest being fifty-two, and the youngest thirty-six years 
old. They are all in easy circumstances ; five occupy healthy apart- 
ments, the sixth only living in damp rooms on the ground floor. 
Three patients have had gastralgia ; the fourth sciatica, and great 
troubles have shaken his nervous system ; the fifth is subject to vio- 
lent headaches ; and the sixth, a female, seems to have epileptiform 
seizures, and has a double neuralgia. From the above, then, it may 
be concluded that neuralgia and great nervous excitability are pre- 
disposing causes of this strange neuralgic affection. 

In one of the four female patients the catamenia had ceased ; in 
three they had not, and in two of these the neuralgia showed itself 
before and during the menstrual periods. Uterine congestion seems 
then to be a predisposing cause also. 

Four of the six patients had had rheumatic pains ; but the other 
two having never suffered from such pains, this can not be consid- 
ered as the exciting cause of the neuralgic affection. 

The desire to pass water, and especially the act of micturition, 
brings on the sensation, which only appears at those stated times, 



em DISEASES OF WOMENT. 

and it reaches its maximum intensity at tlie beo'lnnino^ of the mic- 
turition. It has all the characters of neuralgia, and can even aggra- 
vate, as in one case, an abeadv pre-existing neuralgia — that of the 
median nerve. 

As to the precise seat of the sensations, we find them affecting the 
four extremities of one patient, but the upper limbs only of the re- 
maining five. In three cases they simulate to perfection neuralgia 
of the ulnai' ; and in two thej are felt in the tips of all the fingers. 
In one case thej coincide with and intensify pains in the coui'se of 
the median ; and lastly, as in the first case we have given above 
they are felt in the distribution of the left radial nerve. 

The first patient complains of pain in both shoulders, especially 
the left ; the fourth, of pain in both arms and hands, but chiefly in 
both breasts, and in the left breast more than the right ; the sixth, 
again, of pain in both forearms and hands, but more marked on the 
left side. Hence, the left side of the body would seem to be either 
the only one afiected, or the one most affected. 

The patients always distinguished clearly the special painful sen- 
sations felt in the urinary passages from the noiTQal sensations due 
to a distention of the bladder and the subsequent desire to pass 
water. 

Retention of Urine Due to Hysteria. — A single lady, thirty-one 
years of age, of delicate organization and pronoimced nervous tem- 
perament, yet very quiet and self possessed in manner, suffered for 
some time ^vith difficulty of urination. At times she could m^inate 
very well, at others she was obliged to try repeatedly before she 
succeeded. She was a lady of high culture and liberal education, 
but was not interestedly occupied, and hence she had much time for 
introspection. 

She called her physician who prescribed remedies, but finding 
that they did not give her relief, made an examination of the pelvic 
organs but could find no cause for her inability to urinate with facil- 
ity. 

Soon after she was taken with complete retention which was re- 
lieved by the catheter. This continued for weeks, requiring the 
doctor to visit her three times a day, and occasionally at night, to 
pass the catheter. For some reason which was not very evident 
and could hardly be due to weakness or suffering, she remained in 
bed most of the period dming which the catheter was used. Be- 
coming weary of such close attention, the doctor tried letting her 
wait, to see if a full distention of the bladder would have any good 
effect. This caused her so much pain that the doctor felt somewhat 



FUNCTIONAL DISEASES OF THE BLADDER. 667 

mortified at his want of feeling in permitting her to suffer. Dur- 
ing this time he had tried a number of remedies, but without 
effect. At this stage of the history I was called in consultation ; 
I could find no evidence of any organic disease, local or general. 
The urine was found upon examination to be normal. I suggested 
to the attending physician that the trouble was hysteria, but he as- 
sured me that she was singularly free from all evidences of that 
affection. Indeed, he had found her a remarkably calm and sensible 
lady, and very free from nervousness of every kind. The impression 
that I received was that there was a very decided hysterical element 
in the case, and I advised full doses of bromide of potassium and a 
sitz bath when she desired to urinate. I also recommended that she 
should go to Saratoga, and drink Hathorn water. She did this, 
and the water gave her diarrhoea, and her retention was immedi- 
ately relieved. 

Freq^uent Urination Due to Hysteria. — A lady twenty-three years 
of age, in very good general health, and Kving in very easy circum- 
stances, had some disappointment which caused her much distress. 
She had faintings of a mild character which alarmed her mother 
and called forth much sympathy. About this time she began to 
suft'er from frequent urination. This did not yield to the treatment 
employed by the family physician, and she was brought to my oflSce 
for advice. Her health was at times excellent, but she was greatly 
annoyed by this frequent urination. The urine was normal except 
at times when it was of a very light color. She could sleep all night 
without being disturbed by a desire to urinate. If by chance she 
did not go to sleep immediately on retiring she was obliged to urin- 
ate every few minutes, and if she was awakened in the night she 
had to urinate many times before she could sleep again. 

Any little mental excitement, such as going to church or to the 
theatre, would bring on the trouble, so that she had to give up all 
pubHc duties and pleasures. Systematic exercise and occupation, 
cold baths, bromide of sodium, and a full assurance on my part that 
she would soon recover, helped her greatly. She was commanded 
in a very decided way to resist the inclination to such frequent urin- 
ation, and she obeyed orders. 

Soon after this her attention was attracted in another and more 
interesting direction, and she recovered completely. 

Frequent Urination from Perverted Sexual Function, — A girl 
nineteen years of age who had a good general organization and en- 
joyed good health up to puberty at fourteen, sought advice regard- 
ing impatience of her bladder. She was obliged to return home 
44 



DISEASES OF WOMEN. 

from boarding-seliool because she had to urinate so often that she 
could not attend to her studies and recitations. Her general nutri- 
tion was good, she menstruated regularly, freely, and without acute 
pain. Her nervous system was depressed. She was sometimes lan- 
guid, low spirited and fretful, at other times she was bright and dis- 
posed to be cheerful. Her manner was rather timid and excited. 
Her hands were clammy, and her eyes dull, and had dark streaks 
under them. Her chief symptom was the frequent urination which 
persisted but was much worse at times than at others. Occa- 
sionally she would pass the night without getting up more than 
once or twice, but during the day she was often obhged to urinate 
every half-hour. There was very little pain except occasionally a 
little smarting at the meatus. She complained of heat and burning 
about the vulva and occasional aching in the region of the ovaries. 
She was easily fatigued and had backache, especially on standing and 
walking — leucorrhoea troubled her only at times. 

I suspected at first that she had either cystic and urethral con- 
gestion, or else hysteria giving rise to excessive renal secretion of 
limpid urine, but an examination of the quantity and composition of 
the urine proved the contrary. She was put in charge of a very 
competent nurse who was directed to find out the habits of the 
patient. 

The report of the attendant was that she had begun to indulge in 
masturbation soon after puberty, and that the habit had gradually 
grown upon her. Her nurse surprised her by telling her the cause 
of her suffering, and readily gained her consent to make all due 
efforts to recover her self-control. By care, occupation, and exercise 
out-of-doors, and the moral control of her nurse, she began to im- 
prove. Bromide of sodium was given when she was very restless 
and irritable, but no other medication, except the free use of 
bathing. 

In about two months the frequent urination had disappeared, al- 
though she would occasionally have a day or a night when she suf- 
fered in that way a little. She now has two children, and enjoys 
life very well, being free from her former symptoms and no doubt 
cured of her former habit. 

Frequent and Difficult Urination from Sexual Continence. — The 
patient, a strong and active lady in good circumstances, was married 
at twenty-one years of age, and had her first baby before she was 
twenty-two. She nursed the child for eighteen months. Her 
menses came on when the child was one year old. About three 
years after her marriage, her husband, a strong, vigorous man, died 



FUNCTIONAL DISEASES OF THE BLADDER. 6G9 

of pneumonia. Several months after the loss of her husband she 
be^an to suffer at times from frequent urination, and also had some 
difficulty in voiding the urine, requiring voluntary efforts. These 
attacks would pass off, and she would be comfortable for days, 
when the same irritation of the bladder would return. She was 
always made worse by excitement, often being kept awake nearly 
all night after spending the evening in company. 

Her symptoms became so troublesome that she sought advice of 
a physician, who treated her for cystitis by giving medicines of va- 
rious kinds. When she first came under my observation I found 
her in perfect health in every way. The urine was normal, and 
caused no pain when she passed it. I was easily able to exclude all 
diseases except deranged innervation from a possible malarial influ- 
ence. The periodical character of the attacks favored this view of 
the case, but the use of the anti-malarial remedies gave no relief. I 
then ordered her to take more active exercise and a limited quantity 
of plain food, to bathe frequently, and to avoid excitement as 
far as possible. Bromide of sodium was also given when her 
suffering was most severe. She improved on this treatment for a 
time, in fact she became so much better that I lost sight of her for 
nearly a year. She returned to say that her former symptoms had 
returned, and were about as troublesome as before. The same treat- 
ment was employed but did not help her Yerj much. She was 
now rather nervous and restless, and disposed to be emotional. 

Three months afterward she was married, and left the city on 
an extended wedding-tour. Upon her return she reported herself 
as perfectly well. 

A Case of Malarial Irritation of the Bladder in the Female. (By 
Henry K. Leake, M. D., Dallas, Texas. Abstract of a paper read 
before tlie Texas State Medical Association.) I desire to record 
an observation, which I have recently made, exemplifying the 
effect that the malarial poison may exert upon the female blad- 
der ; an observation which may appear commonplace since, as is 
well known, it has not escaped mention by Prof. Skene in his excel- 
lent work on the " Diseases of the Bladder and Urethra in the 
Female" as well as by other authors of equal or less prominence, 
who have attended to the same subject. 

Nevertheless, considering the mere allusions by these writers to 
irritation of the bladder in women, which may be caused by tlie 
presence of malaria in the system, on account, doubtless, of the rare 
occurrence of this affection, it may be questioned whether the latter 
has been sufficiently individualized as a distinct and independent 



670 DISEASES OF WOMEN. 

malady, deserving especial prominence in the nosology of diseases of 
the bladder, which seriously disturb the functions of this sensitive 
viscus. There is the additional reason, also, for reporting the ex- 
perience which I have had of this peculiar and interesting disorder, 
in the fact that much obscurity yet surrounds the entire subject of 
disturbance of the functions of this organ in the female, the integrity 
of which is so vital to the comfort, happiness, and safety of the in- 
dividual. 

Moreover, such conditions often tax the diagnostic acumen of 
the physician to the utmost, and even when by the exclusive method, 
rigorously employed, many causes of irritation of the bladder may 
be eliminated from the problem in hand, there will yet remain in 
particular cases, other causes which may elude discovery, thus ob- 
scuring the pathogeny and defeating every measure of treatment 
which is attempted. 

About March 1st, of the present year, a lady, whose health has 
been uninterruptedly good, thirty-seven years of age, the mother of 
six children, the last of which being an infant of four months, ap- 
plied to me for treatment for what she considered the ailment to 
be, incontinence of urine. She stated that the condition had come 
on gradually, at the first amounting to a mere frequency of urina- 
tion during the day, without any attendant pain or other symptom 
which attracted her attention. This frequency had increased, how- 
ever, to such an extent as to seriously embarrass her in the perform- 
ance of domestic duties, and prevent her from visiting friends, or 
doing necessary shopping. Moreover, she sgon became troubled at 
night, often rising six or, perhaps, a dozen times, in obedience to 
the urgent calls for micturition. The amount of urine passed at 
each discharge was not large, but exceeded in quantity that ordi- 
narily retained in cases of acute cystitis, which the affection in 
many respects closely resembled. 

There were no deposits in the urine worth noting. It appeared 
to be somewhat higher colored than normal. There was also a 
superabundance of mucus, in the form of large flocculi, but no pus 
or blood. 

As the case progressed, the desire to evacute the bladder was 
preceded by a sharp twinge of pain, which the patient averred was 
" low down at the very neck of the bladder," but which was imme- 
diately relieved on emptying the viscus. There was no tenderness 
at any point except a slight pain experienced when the neck of the 
bladder was firmly pressed toward the pelvis. 

The frequency of micturition increased to almost constant drib- 



FUNCTIONAL DISEASES OF THE BLADDER. 671 

bling from the bladder, both daily and nocturnally the cloud of 
mucus in the urine was much augmented, and while the color ap- 
peared to remain unchanged, there was evidently a large excretion of 
solid matter composed probably of phosphates. 

The uneasiness elicited at the neck of the bladder by pressure on 
this part soon changed to actual soreness. At the end of the second 
week the case had passed into one of apparently serious import, and 
was operating with telling effect on the vitality and mental equipoise 
of the patient. 

The tripod of treatment, namely, rest, opium, and alkalies, upon 
which Yan Buren and Keyes cogently protest the successful manage- 
ment of cystitis rest, was relied on to relieve what I now feared 
was a case of this distressing disease, the cause of which I could 
not then determine. The constitutional effect of belladonna was 
evoked also to mitigate the symptoms, and finally hot-water vaginal 
injections were employed for their well-known analgesic and anti- 
phlogistic effects upon the pelvic viscera. 

Such measures gave only temporary relief, the features of the 
case resuming their original character whenever the effect of medi- 
cation — which was occasionally suspended to ascertain the status quo 
of the disease — had passed off. 

At the beginning of the third week from the first appearance of 
the symptoms, the patient complained of slight chilliness toward 
evening, and it was observed that this was followed by fever, the 
thermometer in the mouth registering 101.° These symptoms were 
interpreted to indicate the constitutional expression of the local in- 
flammation existing in the bladder. Hence, no special attention was 
directed toward them. The chilliness was repeated, however, on the 
third evening, and on the fourth day at the same hour reappeared 
as the prodrome of a marked rigor, followed by an abrupt rise of 
temperature of 103° succeeded by sweating and a return to the 
normal temperature in about four hours, thus clearly demonstrating 
a well-defined periodicity of the febrile movement. 

Suspicion being now aroused as to the essential nature of the 
case, the patient was promptly placed on ten-grain doses of the sul- 
phate of quinine, to be taken every four hours with mercurial and 
saline purgatives, the latter being indicated by the appearance of the 
tongue and the confined state of the bowels, which was due not alto- 
gether to the opium administered, since this physical modifier had 
been exhibited both freely and simultaneously. 

The substitution of the quinine for the treatment previously 
pursued, like the fabled wand of the magician, broke the spell ol 



672 DISEASES OF WOMEN. 

encliaiituient, wMcli, bv its subtle and potent influence had held 
the patient with relentless grasp for three weeks and had trans- 
formed a hopeful and contented disposition into one of melancholy 
and apprehension. 

At the end of four days from the administration of the first 
dose of quinine the patient was virtually convalescent. During this 
period no opiate was employed nor any other medicine but quinine 
taken, save an occasional dose of neutral mixture, chiefly for its su- 
dorific effect. J^evertheless the irritation of the bladder did not re- 
turn, and the close of the week found the patient, although debili- 
tated by the trying ordeal through which she had passed, enabled 
to resume her accustomed duties. 

Periodical Attacks of Frequent and Painful Urination and Vesical 
Tenesmus caused by Malaria. — About two years ago a patient came to 
my college clinic complaining as follows : In the afternoon of each 
day she experienced a sense of heat and burning in the bladder and 
urethra, with a frequent and irresistible desire to imnate. Evacua- 
tion of the bladder, attended with a great deal of smarting and pain 
in the urethra, did not give complete relief but left some vesical 
tenesmus which increased in severity as the bladder became dis- 
tended. These symptoms persisted during the night and kept her 
awake, but toward morning her sufferings entirely left her, and she 
became quite comfortable until the next afternoon. This condition 
had existed for nearly two months, and accordingly her digestion be- 
came impaired and her strength diminished. This was attributed 
by her to the want of sleep, and no doubt in part was due to this 
cause. The urine was examined, and found to be normal except that 
it contained a slight excess of phosphates. She was carefully exam- 
ined, and no evidence of organic disease was found. While she al- 
ways enjoyed full health and had been a vigorous woman, she had had 
an attack of malarial fever about six months before I saw her, and 
about the time this bladder trouble came on she said she had symp- 
toms of her former ague. From the facts in her history I ventured 
to state to my class that this was a functional derangement of the 
bladder and urethra caused by malaria, which would promptly yield 
to judicious doses of quinine. I accordingly prescribed twenty 
grains of quinine to be taken between early morning and noon, to 
be followed by two-grain doses before meals with four drops of 
Fowler's solution of arsenic after meals. She was ordered to report 
at the clinic the following week. She did so, and declared that she 
had been perfectly well since the first day she took the medicine. 
The quinine and arsenic in small doses were continued for three 



rUKCTIONAL DISEASES OF THE BLADDER. 673 

weeks, at tlie end of wliich time she reported herself as having been 
well and free from all irritation of the urinarj organs. 

No change in the character of the urine could have occurred to 
produce such marked periodicity in the functional derangement of 
the bladder and ui-ethra ; moreover, the urine was found to be nor- 
mal, and she completely recovered on the use of quinine. 

Vesical Tenesmus and Frequent Urination due to Prolapsus and In- 
flammation of the Ovaries. — In prolapsus of the ovaries and inflamma- 
tory affections of these organs irritation of the bladder often occurs. 
This is illustrated by the following case : 

A young girl of twenty-one was brought to me suffering from 
great distress in the pelvis, which was much aggravated by standing 
or walking. Her suffering was constant, but was tolerable when she 
remained in the recumbent position. She began to complain about 
six months before I saw her, and about the same time she found 
that she was obliged to urinate too often, and that there was an un- 
easy feeling in the bladder most of the time, a feeling as if the 
bladder had not been fully evacuated. 

She was much worse at her menstrual periods. Upon a thor- 
ough examination I found both ovaries prolapsed, slightly enlarged, 
and exceeding tender. In every other respect she was perfectly 
well. In consultation with her physician, a course of treatment for 
the ovarian disease was decided upon. This was fully and faithfully 
tried for over one year, but at the end of that time she was worse. 

She was then quite impatient, being very nervous and irritable 
from her confinement and suffering. Her parents and friends were 
quite weary of seeing her suffer. Her bladder irritation was no 
better ; in fact it was a great source of suffering. She could not 
urinate without getting up, and the erect position increased her 
ovarian pain. The ovaries were still prolapsed and just as tender, 
in fact, more so than they had been. 

The complete failure of treatment so far indicated that removal 
of the ovaries was the only thing that promised to give her relief. 
Accordingly the ovaries were removed, and she made a rapid recov- 
ery from the operation and was completely relieved not only from 
her ovarian pain but also from the frequent urination and vesical 
tenesmus. 

It should be stated that at no time was there any evidence of 
cystitis found upon frequent and careful examinations. 



CHAPTEE XXXYIIT. 

FUNCTIONAL DISEASES OF THE BLADDEU (cONTINUEd). 

Haying considered tlie vesical derangements in which there is 
no recognizable organic lesion, and which may be local neuroses, or 
may be due to hysteria, disorder of the sexual function, malarial or 
ovarian affections, I will now invite attention to the second class of 
these disorders. 

I. Derangements of function due to diseases of the nutritive and 
nervous systems, or to abnormal conditions of the urine which re- 
sult therefrom. 

This class naturally subdivides itself into : 

1. Derangements occurring in both acute and chronic diseases. 

2. Derangements due to consequent abnormal conditions of the 
urine. 

1. Of the derangements which occur in the course of acute dis- 
eases, such as retention and incontinence of urine and frequent urin- 
ation, nothing more than the mere mention is necessary. They 
rarely require any treatment, except possibly in the case of reten- 
tion, when catheterization is to be employed, and they cease as soon 
as the acute stage is passed. Those, however, which are due to 
chronic affections of the nutritive and nervous systems are more 
permanent, and often tax the resources of the physician to the 
utmost. The two most important are : 

(a) Paralysis of the bladder, and, 

(h) Incontinence of urine. 

{a) Paralysis of the Bladder. — This affection has also been de- 
scribed under the names of weakness or palsy of the bladder, and 
vesical atony. It occurs in two forms : First, from causes residing 
in the organ itself ; second, from those due to outside influences. 
As affections in the first form wiU be fully described in another 
place I shall here simply mention them. They are : Fatty degenera- 
tion and atrophy of the muscular walls of the bladder, a common 



FUNCTIONAL DISEASES OF THE BLADDER. 675 

cause of paralysis of tliis viscus in old women ; overstrain of the 
muscular structure from prolonged retention, voluntary or involun- 
tary ; displacements and inflammations of neighboring organs affect- 
ing its position or nutrition ; and abdominal and pelvic tumors. 

In fevers of a serious type the power of nerve conduction may 
be either lost or impaired, and a partial or total vesical paralysis re- 
sult, with overdistention and dribbling of urine. 

The second form is due to influences acting from without the 
bladder, and includes acute and chronic meningitis ; apoplexies of 
the brain or spinal cord ; sopor ; delirium ; myelitis of the lower 
part of the spinal cord ; inflammation of any kind primarily affect- 
ing or involving in its results either the lumbar nerves or ganglia ; 
endarteritis deformans of the pelvic arteries ; lumbar or renal ab- 
scesses ; blows or fall upon the loins, supra-pubic region, or head ; 
shock or disease of the vesical or lumbar nerves from the prolonged 
use of opium or poisoning by it, and also shock due to overdisten- 
tion of the organ itself. 

Symptomatology. — Except in cases of injury of the braiu and 
apoplexies, the invasion of the disease is usually very gradual. This 
is especially the case in the aged, and sometimes, though rarely, in 
young people. The patient first observes that the urine is expelled 
from the bladder with less force than usual ; that the act of empty- 
ing the bladder is more slowly accomplished, and that after a time 
the organ is unable to expel its contents without considerable strain- 
ing and aid from the abdominal muscles. At a later date, if the 
disease goes on unchecked, the stream is less and less forcibly ejected, 
intermits, and the bladder, after much straining, is but partially 
emptied. Finally, partial or complete retention follows. 

The female bladder seems to be capable of more distention than 
that of the male. Lieven, in a case of supposed ovarian tumor, re- 
moved by catheterization about nine pints of urine. The patient was 
a woman thirty-three years of age. The fundus of the bladder 
reached as high as the ensiform cartilage. I once saw a case exactly 
like this, except that the bladder only reached to about two inches 
above the umbilicus. More than a gallon has been drawn off by 
Hofmeier and others. 

A peculiarly interesting experiment bearing upon the dilatability 
of the bladder was made by Budge. He found that section of the 
lower part of the spinal cord, when the bladder was considerably 
distended, allowed increased reflex action of the sphincter, and 
enormous distention then took place — even more than could be pro- 
duced by force, after death. This is especially interesting in rela- 



676 DISEASES OF WOMEN". 

tion to vesical paralysis and retention due to injury or disease of the 
lumbar portion of the spinal cord. 

In some cases of overdistention the resistance of the sphincter is 
overcome somewhat, and a constant dribbling of urine takes place. 
It has been called by some authors incontinentia parodoxa. These 
cases are liable to be mistaken for those of pure incontinence. 

In rare cases rupture of the bladder may take place ; more com- 
monly dilatation of the ureters and hydronephrosis. If the condi- 
tion of vesical distention be not soon relieved, vesical catarrh, true 
inflammation, ulceration, and death take place. In cases due to in- 
jury or disease of the spinal cord, low down, there seems to be a 
paralysis or peculiar condition of the nerves presiding over the nu- 
trition of the vesical mucous membrane, and destructive changes are 
not uncommon. 

Diagnosis. — The diagnosis though easy, is sometimes not made, 
owing to careless observation or ignorance. When called to a case 
where there is supposed distention of the bladder, the abdomen 
should first be examined to see if there are signs of a tumor, and 
then a catheter should be passed if that be possible, to determine 
whether an abnormal amount of urine is present. If this is the 
ease, and the tumor gradually subsides as the urine flows, the diag- 
nosis is at once made. When, however, a catheter can not be passed 
into the viscus, fluctuation should be sought both through the vagina 
and on the surface of the tumor. If the diagnosis be still obscure, 
the aspirator-needle should be passed into the tumor, and its fluid 
contents carefully tested. The age of the patient, the duration of 
the disease, and its time and method of invasion will aid in settling 
the question. The trouble may, however, occur at almost any age, 
and the fact that a little urine has been passed at short intervals 
will tend to deceive. 

In the early stages of the disease an idea can be gained as to its 
progress by carefully noting the amount of urine passed at each 
micturition, the amount passed in twenty-four hours, the length of 
intervals between urination, the force of the stream, whether the 
bladder is fully or but partially emptied, and whether the stream 
intermits. The urine should be examined often, else cystitis may 
get a firm foothold before its existence is recognized. In drawing 
off the urine for testing or other purposes, the catheter should be 
absolutely clean. 

Incontinentia paradoxa must be differentiated from incontinence 
due to mechanical causes, such as abnormal urine, or the pressure of 
neighboring organs upon the bladder. 



FUNCTIONAL DISEASES OF THE BLADDER. 677 

Prognosis. — If tlie disease be uncomplicated the prognosis is 
good. Paralysis of the organ accompanying the fevers, dysentery, 
peritonitis, and the like, usually disappears with the cure of the 
original disease. 

If the paralysis be accompanied by disease of the bladder-walls, 
or if it occurs in weak, debilitated constitutions, or has been of long 
duration, or occurs in old age, the prognosis is not good. A cure, 
if effected at all, will be only after long and tedious treatment. 

When due to centric causes or to serious spinal disease or injury, 
or when it occurs in old people, or with meningitis, or with sys- 
temic trouble, the prognosis is very grave indeed. 

Causation. — Deranged innervation due to the central lesion 
already mentioned, either cerebral or spinal, may be regarded as 
the principal cause of this affection. If the paralysis has been of 
long duration nutritive changes may occur in the bladder, but as 
these will be discussed under the appropriate head I need say noth- 
ing of them here. 

Treatment. — In all cases where there is fear of vesical distention, 
the bladder should be emptied at stated intervals. ^j way of 
helping the patient to pass water herself, hot hip-baths may be tried 
and fomentations over the bladder. The sound of water falling 
from one vessel into another often accomplishes the same result. If 
these means do not succeed the catheter must be used. 

And here attention may be called to a very important practical 
point in connection with the use of the catheter. When the blad- 
der has become very much distended it can not be thoroughly emp- 
tied unless pressure is made upon the abdominal walls ; if this press- 
ure is made while the catheter is in the bladder, and then discontin- 
ued, air will be drawn through the catheter into the bladder and 
decomposition of the urine will thus be favored. 

Marked distention can usually be relieved by the catheter. In 
some cases, however, the bladder rises up into the abdomen and 
puts the urethra upon the stretch, thus changing the direction of its 
axis from the normal to one from below directly upward, the canal 
being nearly parallel to the posterior surface of the pubic symphy- 
sis. In these cases passing the catheter will tax the skill somewhat. 
Great care must be used to avoid injuring the urethra. 

In emptying a greatly distended bladder a binder should be ap- 
plied to the abdomen and tightened gradually as the urine flows. It 
is not safe to draw off all the urine at once. It is better to take 
away about half, and then after a time to draw off more, until the 
organ is empty. Syncope and even death, which is said to have 



678 DISEASES OF WOMEN. 

occurred in these cases after rapid emptying of the organ, are prol> 
ably due to the sudden removal of the pressure on the abdominal 
organs, which so deranges the circulation as to cause these serious 
results. The sudden removal of pressure from the vesical walls, 
which that pressure rendered anasmic, now allows intense conges- 
tion, and the vesical walls being paralyzed catan^h and cystitis result. 
Therefore, for many reasons, a distended bladder should be emptied 
slowly. 

When, for any reason, a catheter can not be introduced into the 
bladder, hot hip-baths should be again tried, and opium given in suf- 
hcient amount to relieve pain and any spasmodic action that may 
exist. If, after this, there is failure to enter the bladder (and it is 
only in very rare cases that this occurs), recourse should be had to 
the aspirator, and after having punctured the bladder, the urine 
should be drawn slowly and carefully, in the manner already de- 
scribed. 

In commencing vesical paralysis, and when incontinentia para- 
doxa exists or has existed, the patient should be taught to use the 
catheter herself several times daily until the vesical power returns. 

It is of the utmost importance that the catheter be absolutely 
clean. After each time that it is used it should be thoroughly rinsed 
in a chlorine solution, and put away in carbolized oil or vaseline. A 
great deal of vesical catarrh is undoubtedly lighted up by foul cath- 
eters. This is especially the case in hospitals, where the same in- 
strument is often used on a number of patients. 

In cases of commencing or established paralysis the effect of the 
induced electric current may be tried. One pole thoroughly insu- 
lated up to the point to be used should be placed in the bladder, 
and the other over the pubic symphysis and loins, letting the cur- 
rent flow in various directions, through, over, and into, the affected 
organ. The German authors, especially Winckel, by whom this 
method is highly recommended in this and like affections, say that 
the sitting should last but about five minutes. 

Forcibly distending the urethra and washing out the bladder 
with a solution containing sal icy he acid has been tried and recom- 
mended. I can not see the expediency of this unless vesical catarrh 
exists ; and even then washing must be done gently and carefully, 
and without previous dilatation of the urethra. 

Attention should be paid to the general health. The food should 
be good and nourishing, and the alimentary canal kept in a proper 
condition to receive and digest it. Wines (especially champagne), 
beer, and ale may be of use. I can at least say if stimulants are 



FUNCTIONAL DISEASES OF THE BLADDER. 679 

ever given in diseases of the bladder it should be in cases like these 
now nnder consideration. These patients are usually more com- 
fortable in the standing or sitting, than in the prone posture, be- 
cause then the weight of the abdominal viscera replaces to a cer- 
tain exteut the natural tonicity of the organ. As they are usually 
worse in winter than in summer it is advisable, if the case is 
chronic and the patient able to bear transportation and rich enough 
to meet the expense, to send her to a moderately warm climate 
during the winter months. This will apply in most of the diseases 
of the bladder. 

If the trouble be purely atonic, camphor or musk may be used 
internally. Tincture of cantharides, in from live to twenty drop 
doses, three times a day, has been recommended as a vesical excit- 
ant. I can not indorse its use without the caution that besides the 
tendency to irritate the kidneys and produce congestion and 
nephritis, it may light up a severe cystitis. In these cases it m.ay 
produce serious trouble without causing much pain to give warning 
of the danger, as the paralysis lessens the sensitiveness of the blad- 
der, so that destruction of tissue may occur without producing the 
usual pain and suffering. 

Strychnia has been extensively used in this complaint, and with 
good results in some cases. Its failure to do good in many in- 
stances is undoubtedly due to the fact that it was not given in suffi- 
ciently large doses. It may be safely pushed as high as the one- 
twentieth of a grain three times a day, stopping for a few days if 
any of its characteristic symptoms appear. It has also been used 
hypodermically in the neighborhood of the bladder. 

Ergot has been found useful in cases where the paralysis was 
due to exposure to cold, or prolonged retention from any cause. 
The fresh powder has been recommended, and may be given in doses 
of from eight to sixteen grains, four or five times daily. It is more 
pleasant and probably more effective to give its equivalent of the 
fluid extract. Alliers has used it with decided success in cases of 
vesical paralysis due to centric troubles, such as apoplexy. He has 
used as much as forty-five grains in the twenty-four hours. It is 
highly spoken of also by Roth, Jacksch, and others. 

Eutenberg (" Wienner Med. Wochenschrift," 1875, Ko. 37) has 
recommended, in cases where there is destruction of muscular tissue 
or incurable paralysis from any cause, to make an opening into the 
bladder just above the pubic symphysis, keeping the fistula open, 
and closing the urethra by operative procedures. The urine can 
thus be retained, unless the patient bends forward and downwai'd 



680 DISEASES OF WOMEN". 

or lies upon her abdomen, A urinal would, of course, be necessary 
to protect the patient. 

I think I should prefer to produce a vesico-vaginal fistula, and 
adapt an apparatus to receive the urine. 

(h) Incontinence of Urine. — Enuresis nocturna is usually an affec- 
tion of childhood, but has been known to persist up to the age of 
thirty years. In some children it is hereditary, the mother having 
suffered in early years, and all the children born to her being affected 
in the same way. Of all cases, these are the most difiScult to manage. 
They often persist until puberty, when they recover of themselves. 
The subjects of this affection are usually of the weak, nervous type, 
although apparently healthy children have been known to suffer 
from it, but usually only at intervals. 

These cases of incontinence may be divided into two distinct 
varieties: First, the aneesthetic variety. An excellent example of 
this class is seen in infants who, up to a certain age, wet the bed and 
their diapers. In the infant this is not disease ; it is simply a good 
normal example of this condition ; the incontinence in severe fevers 
illustrates the abnormal phase of the same thing. Second, the hyper- 
SBsthetic variety, which is really nothing niore than irritable bladder. 
Each variety may exist alone, or both be combined in the one case. 

In the first variety the retaining power is defective, the resisting 
power of the sphincter being insufficient to retain the urine or wake 
the child. When it is put to bed, it sleeps soundly through the 
night, and the nerve susceptibility to urine-pressure on the neck of 
the bladder, being lowered beyond the normal degree, fails to wake 
the little subject and impress it with the necessity of calling the 
sphincter muscle into action sufi^iciently to resist the expulsive power 
of the bladder-walls. In short, in soand sleep the balance between 
the resisting power of the sphincter and the contractility of the walls 
of the bladder is disturbed, and the urine flows away without the 
child's even dreaming of its unfortunate behavior. 

In other forms of this affection the brain takes cognizance of the 
desire to urinate, but too late to control the act. This is seen in 
children who awake crying when urination is but just begun or half 
finished. In this case the fault probably lies in the vesical nerves. 

In the second variety there is an irritable condition of the blad- 
der (vesical hypersesthesia), which renders the expelling power 
greater than that of resistance or retention, and, while the will and 
cerebration generally are lost in sleep, the contents of the bladder 
are unconsciously passed before the subject wakes to resist the act. 
Closely allied to this is the peculiar affection known as vesical chorea, 



FUNCTIONAL DISEASES OF THE BLADDER. 681 

in wliicli tlie cliild while awake, it may be in school, in church, or 
at play, suddenly experiences the sensation that it is about to make 
water, but, before it is possible to resist, the urine is forcibly spurted 
out. There are usually choreic movements of other muscles or groups 
of muscles. This affection is the most annoying when the little ones 
are nervous, cross, and fidgety. It may be accompanied by nocturnal 
enuresis. It is apparently more common in the male than in the 
female child. 

An irritable condition of the bladder may coexist with an an- 
sesthetic condition of the sphincter vesicae — i. e., the two causes of 
incontinence may be combined. 

Irritable bladder, it should be remembered, may be due to some 
systemic condition — that is, a simple neurosis or to abnormal urine, 
or reflex irritation from anal fissure, ascarides in the rectum, fistula 
in ano, haemorrhoids, or vulvitis. 

Enuresis nocturna is not only a filthy habit, and a source of great 
annoyance to parents, but, moreover, by keeping the genitals wet 
and irritable, strongly predisposes to masturbation. Then, too, other 
serious results may happen. The constant wettings are dangerous, 
in that they may produce many serious complaints from causing the 
child to " take cold." 

Prognosis. — In some cases the cure is easily and speedily ef- 
fected ; in others, the disease cures itself at or just after puberty ; 
but in a few — a very small percentage — no medical or other means 
seem to aid the sufferer at all. 

Treatment. — That the treatment is not uniformly satisfactory is 
seen by the number of remedies that have been tried. The proper 
way — and I can not call attention to this too often — here, as else- 
where, is to find the cause producing the disease, if it be discovera- 
ble, and it generally is. The treatment will, of course, differ in the 
two classes, and be greatly modified by diathesis and idiosyncrasy. 
In ansesthesia, local or general, stimulation is indicated. In hyper- 
a^sthesia, irritability should be allayed. 

Winckel, Barclay, and Brugleman speak very highly of the use 
of the syrupus ferri iodidi, the last-named gentleman having by its 
u:se cured a girl perfectly of incontinence in the short space of four- 
teen days. This result was probably due more to the effect of the 
medicine on the blood and general system than to any specific action 
on the bladder. The sirup of the iodide may be given in from ten 
to thirty minim doses three or four times daily, according to the age 
of the patient. 

Although belladonna has been lauded by many as a specific in 



682 DISEASES OF WOMEN, 

this disorder, its success is by no means general. The drug is usually 
given by the mouth in from five to twenty drop doses of the officinal 
tincture. It would be better to begin with small doses in young 
children, and gradually increase them ; for, although no serious re- 
sults may come from its exhibition in the routine dose — ten drops — 
the parents may be greatly alarmed by the peculiar redness of the 
skin produced in some cases. It is maintained by some medical men 
that the good effects are not obtained unless the administration be 
pushed to the appearance of the scarlet rash. There is, I think, no 
proof of the correctness of this statement. 

A combination of belladonna and chloral hydrate has been used 
and well spoken of. Winckel, however, though using them in cer- 
tain cases for a long time, and daily increasing the amount of chloral, 
has had but poor results, and even in those cases where the patients 
improved the benefit was seldom permanent. These drugs may be 
given singly or together, in suppository or by the mouth. If given 
together, they should not be combined until the time when they are 
administered, lest the chloral lose its power. 

I^arcotics with tinctura ferri chloridi have been recommended 
by Campbell Black. Winckel speaks well of five to ten drop doses 
of tinctura thebaica, to a child from ten to fourteen years of age, just 
before retiring. According to Sauvage, cold baths and cold douches 
to the spine at night are of great service. 

Dr. Kelp (" Le Mouvement Med.") reports that he has, on sev- 
eral occasions, drawn attention to the value of subcutaneous injec- 
tions of the nitrate of strychnia in the treatment of obstinate cases 
of nocturnal incontinence. He practices the injections in the neigh- 
borhood of the sacrum. A single injection of a very small quantity 
of the drug suffices to arrest the aifection for a certain time, and 
when it reappears the operation can be repeated. His latest paper 
cites the case of a young woman, eighteen years of age, who had 
suffered from enuresis every night for several months ; it came on 
after an attack of scarlatina, and persisted in spite of all precautions. 
The first injection produced a respite of several nights, and the 
second produced a permanent cure. The patient was a strong, 
healthy girl, and had never suffered from enuresis previous to the 
attack of scarlatina. 

Such a plan of treatment I regard as useful only when there is 
deranged innervation, characterized by weakness. It would be diffi- 
cult to get a child to submit to these injections, and I should in any 
case, whether child or adult, expect the incontinence to return as 
soon as the strychnia was discontinued. 



FUNCTIONAL DISEASES OF THE BLADDER. 683 

In cases where tlie vesical irritability is due to abnormality of 
the urine, such as lithiasis, oxaluria, and acidity, these conditions 
should be corrected in the manner I have already pointed out. If 
to ascarides, anal fissure, and that class of rectal trouble, when the 
cause is removed the result will usually disappear also. In irrita- 
bility the usual soothing and demulcent drinks, such as have been 
already recommended, should be used. Oil of sandal- wood has acted 
remarkably well in some of these cases. Bromide of sodium and 
tincture of nux vomica have been effectual in some cases. 

In the anaesthetic variety, where the ansesthesia is more or less 
marked, special or local and general stimulants should be employed. 
N^arcotics are as hurtful here as they are useful in the hypergesthetic 
class. Strychnia by the mouth, in suppository, or hypodermically, 
often produces good results, as also quinine, whether the presence 
of malaria is suspected or not. Tonic and astringent injections into 
the bladder are sometimes of service. In cases of abnormally small 
bladder, forcibly washing it out, distending the organ a little more 
each time, is well spoken of. In one such case, where there was 
irritability, Winckel produced a cure by first injecting a solution of 
nitrate of silver, and following it with sulphate of morphia. This 
treatment, however, applies more to the irritable than to the anaes- 
thetic type. The little patients are very hard to operate upon, and, 
unless great care is exercised, much mischief may be caused by local 
treatment. 

Winckel claims good results from the use of the electric current, 
applied in the manner I have spoken of under the head of paresis 
vesicae. 

When the bed-wetting is due to pure carelessness, laziness, fear, 
or dread of the cold air in rising, in idiots and half-witted children, 
much may be gained by proper education. 

There is a general plan of prophylaxis recommended by common 
sense, viz., the heartiest meal should be in the middle of the day; 
but little water should be taken toward evening ; the food should be 
plain and unseasoned ; the bowels should be kept regular ; no coffee 
or tea should be allowed ; the little patients should be put to bed 
early, after it is assured that the bladder is first thoroughly emptied ; 
they should lie upon a hard bed, with not too much covering ; the 
air in the room should be maintained fresh and pure ; the genitals 
should be kept clean and dry ; no places of amusement should be 
visited after dark; and they should be awakened occasionally to 
urinate, especially at about the time the parents are going to bed. 
When it is discovered that they have wet the bed, they should be 
45 



684 DISEASES OF WOMEN". 

awakened, and talked to and reasoned with, if thej are able to com- 
prehend what is said and meant. Children should not go to school 
too early, or stay too long. If the enuresis be due to masturbation, 
the parents must be cautioned to watch closely, and to use every 
means in their power to stop it. A child should never be whipped 
for the offense or misfortune of wetting the bed, unless the inconti- 
nence be due to pure laziness. 

Owing to the fact that incontinence is an affection of childhood, 
and occurs but seldom in women, cases will not be given to illustrate 
what is said in the text on that subject. This omission is made for 
the additional reason that partial incontinence due to displacements 
of the bladder and urethra and from other causes will be discussed 
further on, 

ILLrSTRATIVE CASES. 

Paralysis of the Bladder followed by Incontinence in Case of In- 
sanity. — This was a single lady, twenty-eight years of age, who had 
been insane for eight months. I was told that at first she was vio- 
lent, but had become quiet and rather demented toward the time 
that I saw her. Her physician had observed for some time that her 
bowels were obstinately constipated, and the nurse noticed that she 
had great difficulty in evacuating the bladder. She also appeared 
to have some discomfort in that region ; finally, she went for over 
twenty-four hours without urinating, and then I was called to see 
her. I found the bladder greatly distended, and yet I could not see 
that she had pain or tenderness on that account. The catheter was 
used, and three and a half pints of urine were removed. After this 
the catheter had to be used twice in twenty-four hours for five weeks. 
During this time the usual means were tried to restore the function 
of the bladder, but without effect. The urine then began to flow 
constantly. T\^hen I heard of this, I presumed that the bladder had 
become overdistended, and that the nurse who used the catheter had 
not emptied the bladder. This I found was not the case ; the blad- 
der was empty. The incontinence continued until the patient died 
of general paralysis. 

Paralysis of the Bladder from Cerebro-spinal Menin^tis. — A girl 
twelve years old was taken with cerebro-spinal meningitis, and pre- 
sented the usual clinical history of that affection until the seventh 
day of the disease, at which time the pain had subsided to a great 
extent, but her mind, which up to this time had been clear, began 
to wander. Retention of the urine was noticed by her nurse, who 
called my attention to the fact. I found the bladder distended, but 



FUNCTIONAL DISEASES OF THE BLADDER. 685 

not greatly so. She was asked if she did not desire to urinate, but 
she answered in the negative, so far as I could understand her. The 
catheter was used, and, although the distention was not great, the 
bladder did not contract well, so that abdominal pressure was neces- 
sary to make the urine flow through the catheter. The use of the 
catheter was necessary for some time, during which she improved in 
her general condition, the mind becoming quite clear. She then 
began to express at times a desire to urinate, but could not relieve 
herself. Four days later she succeeded in urinating, but did not 
completely empty the bladder. She gradually improved, but the 
catheter was passed once every twenty -four hours for a week longer. 
The desire to empty the bladder became more and more urgent, and 
she had pain in the urethra in urinating. An examination of the 
urine at this time showed that she had cystitis, due, I believe, to the 
use of the catheter. The cystitis was treated according to my usual 
methods, and she made a good recovery. 

Paralysis of the Bladder from Progressive Locomotor Ataxia. — A 
lady who had been affected with locomotor ataxia for more than a 
year, came under my care for retention of urine. I found that there 
was some decomposition of the urine, but nothing else to distinguish 
the case from paralysis of the bladder, occurring in other cases of 
disease and injury of the spinal cord. The attendant was advised 
to use the catheter regularly, and to wash out the bladder with a 
solution of borax — one drachm of borax to a quart of warm water. 
I learned subsequently that this patient had incontinence of urine 
before she diedo 

II. Derangements due to Abnormal Conditions of the Urine. — The 
bladder being made to contain urine, almost constantly uniform in 
its composition, it at once feels and responds to any abnormality. 
If the aberration is only occasional, the effects are slight and of short 
duration ; but, if the abnormality be constant, or almost so, or if the 
altered urine has a hypersesthetic surface to deal with, the results are 
more annoying. 

Urine which is too acid or too alkaline, too limpid or too greatly 
concentrated, acts somewhat like a foreign body — it irritates, and 
the bladder inclines to expel it. 

Deposits of any of the urinary solids in the viscus may produce 
an irritable condition, and, if unchecked, lead to organic disease of 
the bladder. Uric acid, in large or small crystals, in little masses, 
forming gravel and minute calculi, the amorphous urates, the triple 
and amorphous phosphates (these, as a rule, however, occurring only 
in decomposition of the urine), and oxalate of lime may give rise tc 



686 DISEASES OF WOMEN". 

considerable trouble. There are some other deposits, such as cystine, 
that are of such rare occurrence that they need not be mentioned in 
this list. In any of these caseSj but especially when there is a de- 
posit of uric acid, there may be one of two things resulting ; and, 
in order to treat the case properly, they must be borne in mind : 
First, a real excess of the salt in the urine ; and second, a condition 
of the secretion, where, whether the amount of salt present be nor- 
mal, or less or more than normal, it will be precipitated in the blad- 
der. 

As an example of the first may be mentioned some cases of dys- 
pepsia, when, owing to a defect in either primary or secondary as- 
similation, the salt or salts are eliminated by the kidneys greatly in 
excess of the normal. Here a normal or even an abnormal amount 
of water in the secretion could not hold them in solution, and they 
are consequently precipitated. 

As an example of the second may be taken some cases of hepatic 
disease, in which, although the uric acid is eliminated in abnormally 
small amount, it is precipitated on account of the deficiency of water, 
excessive acidity, and possibly too rapid absorption of the watery 
element of the urine while in the bladder. 

In some cases with an excess of salts, there may be excessive 
acidity and lack of water. Some forms of dyspepsia are notable 
examples of this, and as low nerve condition frequently accompanies 
these disorders, the abnormal urine meets in the bladder with an 
irritable mucous membrane. In these cases the acidity is quite as 
hurtful as the deposit. 

Deposits of oxalate of lime in the bladder are not so common 
(except in lime-water regions) as those of uric acid. In cases of the 
persistent deposit of oxalate of lime in the urine, known as oxaluria, 
there is usually marked irritability of the bladder. This has been 
ascribed by some to the presence of minute octahedra of this salt 
irritating the mucous membrane. It is more than likely, however, 
that the derangement of the general nervous system, always existing 
in these cases, stands as a propter rather than a post hoc^ and that 
the bladder difficulty is but a local manifestation of the general dis- 
ease, and consequently a pure neurosis. That the urine of oxaluria 
does possess irritant properties there is but little doubt, but it is 
hardly likely that the symptoms here occurring would be produced 
unless there was already an abnormal condition of the vesical mucous 
membrane. 

Many authors hold that the high specific gravity of a single speci- 
men of urine must not be taken as an evidence of concentration, or 



FUNCTIONAL DISEASES OF THE BLADDER. 687 

the low gravity of excessive limpidity of the twenty-four hours' 
urine. This is very true in regard to the total amount passed in a 
day ; but as the bladder has to do each time only with the urine in 
it at that time, it will be well in these cases to examine several spec- 
imens in a day, rather than to depend for information on the reac- 
tion of the total amount of urine passed. 

Urine may irritate the same patient at one time from being too 
limpid, and at another time from being too highly concentrated. 
These variations must be carefully watched and treated. A bladder 
that is irritable at all times and with urine of varying reactions, 
may be set down as one affected with a pure neurosis, if no organic 
cause be found, for the urine could not work the mischief continu- 
ally, if normal at certain periods. 

Symptomatology, — Patients suffering from this affection usually 
complain of frequent urination and vesical tenesmus. 

In some cases there is smarting pain in the urethra during the 
passing of water and for some time after, and there is a sense of heat 
in the bladder and a desire to urinate which are not fully relieved 
when the bladder is empty. This last-named symptom belongs 
more especially to those cases in which the urine salts are in excess. 
When the urine is defective in the salts, that is, when the urine is 
hmpid, the only symptom present is frequent urination. It will be 
observed that these symptoms are the same as those presented in a 
variety of affections, and hence can not be depended upon in making 
a diagnosis. 

Diagnosis. — The diagnosis must be made by excluding all other 
conditions which give rise to this derangement of function, and by re- 
peated examinations of the urine, which will show its abnormal state. 

Prognosis, — The rehef of this class of cases will depend upon 
the possibility of correcting the constitutional affections which pro- 
duce the pathological state of the urine. 

In case the abnormalities of the urine persist for a long time 
cystitis and urethritis may be produced. I am sure that I have seen 
cystitis which could be traced to long continued abnormal states of 
the urine. 

Causation,— hi discussing the pathology of this class of func- 
tional derangements the causes which produce them have been fully 
brought out, so that they need not be repeated here. 

Treatment. — In cases of concentration of the urine due to acute 
febrile action, the patient should be liberally supplied with cooling 
drinks ; and as in these affections the urine is generally too acid, the 
slightly alkaline, effervescing waters will be found useful. 



688 DISEASES OF WOMEN. 

In digestive troubles, with excessive acidity or saline deposit, at- 
tention should be paid to diet, bathing, and regularity of the bow- 
els, as well as the taking of a proper amount of exercise. Where 
deposits of uric acid take place there is usually some defect in either 
primary or secondary assimilation. This should be sought out and 
remedied. In excessive acidity with deposits of uric acid, the alka- 
line carbonates act in a double way ; first by neutralizing the acid- 
ity of the urine, and second by acting on the liver to lessen the 
amount of uric acid produced. The following is a very pleasant 
and efficient prescription in these cases. 
!p. Potassii bicarbonatis, 

Potassii citratis aa 3 ss. 

Syrupi simplicis 3 iv. 

M. 

Sig, Take 3 i ii^ half a tumbler of water, adding 3 ij of lemon- 
juice. Drink while effervescing. 

The late Prof. Armor gave some very excellent advice regarding 
the management of such cases, which I will reproduce in his own 
words ; 

" When the urine is acid in any of the forms of cystic irritation, 
great relief is experienced from the use of alkalies, especially when 
administered in an infusion of buchu. I regard buchu as a remedy 
of undoubted efficacy in all cases of vesical irritability. It seems 
to possess similar properties over the urinary tract that bismuth does 
over the intestinal, and is an admirable vehicle in which to adminis- 
ter the various alkalies. The citrate of potash with buchu is an excel- 
lent combination where we desire the joint action of these remedies. 
The liquor of potash, the bicarbonate and the iodide of potash also 
possess a high degree of utility in the class of cases referred to, and 
their therapeutic action is certainly never disturbed by administer- 
ing them in an infusion of buchu. 

" In irritable conditions of the bladder associated with a gouty 
and lithic-acid diathesis, the carbonate of lithium is a remedy of un- 
doubted efficacy. It perhaps excels the preparations of potash in 
rendering uric acid and the urates soluble." 

The following is the formula of a prescription which answers 
well : 

'^. Lithise carbonatis 3 ij- 

Acidi benzoic 3 iij- 

Sodii boratis •. 3 j-. 

Aquge dest 5 i^- 

M. Sig. One teaspoonful in a large glass of water. 



FUNCTIONAL DISEASES OF THE BLADDER. 689 

Limpid urine is usually due to some general nervous trouble or 
cerebral disease. In sucb cases treatment should be directed to the 
original disease. 

Deposits of amorphous or triple phosphates are rare, unless there 
is some organic disease of the bladder. Where the deposits are not 
due to decomposition, some decided nerve trouble is usually pres- 
ent, and here, as in limpidity, the attention must be turned to treat- 
ment of the general trouble. 

In oxaluria attention must be paid to the moral, mental, and 
physical condition, and time must not be wasted in treating mere 
symptoms. In the way of medication, the following prescription 
is looked upon by many as almost specific in these cases : 

^. Acidi nitro-muriatici diluti 3 ^-^j- 

Tincturse nucis vomicae 3 iij. 

Olei gaultherise TT^xij. 

Aquse ad § iv. 

M. 

Sig. — 3 i ii3 water before each meal. In some cases the pure 
non-diluted acid, freshly made up, acts better than the dilute. It 
should be given in omaller doses than the dilute, and in plenty of 
water at the time of taking it. In all cases of urinary deposits, 
water should be freely taken, and the greatest attention paid to 
general hygiene and to mental and moral surroundings. 

Many of the slightly alkaline mineral-spring waters will be found 
of use, acting gently on the liver, flushing the kidneys and urinary 
organs, and shghtly relaxing the bowels. A considerable quantity 
should be taken in the course of the day when the stomach is empty. 

ILLUSTRATIVE CASES. 

Irritation of the Bladder from Abnormal Urine. — A patient forty 
three years old, large and stout, had menstruated scantily for sev- 
eral months and, as the flow diminished in quantity and duration, 
she gained in flesh but not in strength. She had a very good appe- 
tite and lived very well, but she did not feel in her usual health. 
She noticed a gradual disinclination to mental and physical activity. 
Backache, headache, and wandering pains here and there, occasionally 
annoyed her. After these symptoms had continued for a time urin- 
ation became more frequent and at times slightly painful. She 
noticed also that there was a sediment in the urine. These symp- 
toms caused her to seek advice from the fear that she had Bright's 
disease. She was found to possess a very good organization ; and 
thei'e was no organic disease of any kind present. All the evi- 



690 DISEASES OF WOMEN. 

deuces of excrementitious plethora were well expressed iu the abun- 
dant adipose tissue, coated tongue, constipation, muddj appear- 
ance of the eyes, full slow pulse, shortness of breath on exertion, 
depression of spirits, disposition to sleep, and at times sleepless- 
ness. The urine was examined, and found to be slightly alkaline. 
The specific gravity was 1030. There was neither albumen nor 
casts. The salts of the urine were in excess, but as a quantitative 
analysis was not made the exact composition of the urine was not 
obtained. The diagnosis of general excrementitious plethora from 
imperfect elimination was made, and the frequent urination was at- 
tributed to the abnormal condition of the urine. Ten grains of pil. 
hydrarg. and one grain of ipecac were given at bed-time and a Seid- 
litz powder an hour before breakfast the next morning. This was 
repeated in five days. 

The quantity of food was diminished — she had been taking ex- 
tra diet to make her stronger — milk was the chief article permitted, 
with a very little animal food once a day. A Turkish bath twice a 
week and gradually increased out-of-door exercise. The bowels 
were kept rather free by giving a dose of Congress water an hour 
before breakfast every morning. Under this treatment she im- 
proved in every way. The irritation of the bladder subsided, and 
has not returned. The urine is now normal. 

Frequent Urination from Abnormal Urine. — An unmarried lady, 
thirty years old, of good constitution, very ambitious and energetic, 
overtaxed herself during the winter, and toward the end of the 
season, began to suffer from frequent urination and a sense of burn- 
ing heat in the bladder and urethra after urinating. After a time 
these symptoms became very annoying, and as she was a nervous, 
sensitive person, she suffered quite severely. She was found to be 
quite out of health. Her appetite was poor and her digestion im- 
paired ; she was constipated, and suffered from rheumatic pains in 
her joints, and in the back of her neck. In short, she gave a fairly 
good history of dyspepsia and neuraesthenia plus the irritation of 
the bladder which was her chief source of discomfort. The urine 
was diminished in quantity, dark in color, very acid, ai d of high 
specific gravity ; no albumen or casts were found. She had been 
quite free from any affections of the pelvic organs, the present dis- 
turbance of the bladder being the only suffering she had ever had in 
that regard. 

My first impression was that she had cystitis, but there were no 
products of infiammation found in the urine, and therefore the diag- 
nosis was made as stated above. 



FUNCTIONAL DISEASES OF THE BLADDER. 691 

Peptonized milk was ordered with raw eggs, and, in addition, 
barley gruel, clear soups, and bread. Two drops of liquor ammonise 
in a wine-glass of water were given every two hours until the urine 
became normal. Her bowels were kept regular by small doses of 
Kochelle salts and cream-of -tartar taken in the morning. 

Eest was insisted upon, and massage every third day. As soon 
as the urine became less acid and dense, she obtained some relief, 
but was not restored to her usual condition. It was not until her 
general health had been improved that the urine became normal and 
the irritation of the bladder finally left. An interesting point in the 
treatment was observed. For a time she was partially relieved by 
the alkaline remedies, but, when she ceased taking them, the irrita- 
tion of the bladder returned. 

When her general health was restored by rest and tonics the 
urine became normal, and the irritation of the bladder disappeared 
entirely. 

At the present time I have a lady under treatment for specific 
disease of the uterus; during the last four weeks she has had irrita- 
tion, causing frequent urination. She obtains relief by drinking 
very freely of lithia water. 

Case of Baruria (by Dr. Samuel West). — The patient, aged thirty- 
nine, complained, after catching cold, of pains and aching in her 
limbs, which became severe enough after a week to keep her in bed. 
When admitted, these pains continued, but there was swelling of 
joints. The temperature was 100°, and she perspired freely, but the 
sweat did not smell sour. The urine had a specific gravity of 1010, 
and yielded copious crystals of nitrate of urea, with nitric acid. Her 
appetite had been for some days almost absent, and in the hospital 
she took but a little milk or beef-tea. For two days the condition of 
the urine was the same, and the percentage of urea 5*1. This per- 
centage gradually fell to normal, and, as it did so, all the patient's 
symptoms disappeared. The case was regarded as one of baruria. 
The account of the case given by Prout was summarized and com- 
pared with the present case, and reference was made to other authors, 
by some of whom the existence of the affection was questioned, 
while by others it was not referred to. A somewhat similar case, 
the result of overfeeding and constipation, has been described, in 
which like symptoms were associated with a high percentage of urea, 
and disappeared when the amount became normal. 

III. Derangements of Function due to Affections of the Pelvic 
Organs other than the Bladder.— Functional diseases of the bladder, 
caused by disorders of the neighboring pelvic organs, are frequently 



692 DISEASES OF WOMEN". 

met with in practice. In tliis class the vesical trouble is secondary 
to some primary and more important affection, but the derangement 
of its function is often the most prominent and troublesome symp- 
tom ; hence it is important to understand its relation to the primary 
disease, in order to make a correct diagnosis, and to treat such cases 
properly. 

This class of functional disorders frequently resembles in history 
some of the organic diseases of the bladder, so that care is necessary 
to distinguish the one from the other. What I may say upon the 
subject will have reference to diagnosis only. When we know that 
the bladder trouble is due to disease of some other organ, attention 
is at once turned to the primary affection. These facts must be 
borne in mind, and the symptoms not mistaken for the disease. 

Diseases of the rectum affect the bladder sympathetically. Irri- 
tation and pain in the rectum from any cause affect the bladder more 
or less. Chronic haemorrhoids will cause frequent urination, and 
so will rectal fissure, especially after defecation. Abscesses in the 
neighborhood of the rectum will frequently cause retention of urine. 

One very interesting case of this kind occurred in the practice 
of my friend Dr. Gushing. The patient had an abscess in the neigh- 
borhood of the rectum which caused retention of the urine, and this 
in turn caused acute renal disease. After the bladder had been 
emptied and kept from overdistention for some time, the urine was 
examined and found to contain albumen and casts. She made a 
rapid recovery, and all evidence of kidney-disease soon disappeared. 

Yery troublesome vesical irritation may come from ascarides. 
The itching of the anus and rectum, caused by these troublesome 
little worms, keeps up an almost constant desire to urinate. Chil- 
dren are most troubled with these parasites, but women often suffer 
in the same way. 

Marion Sims points out the interesting fact that almost all cases 
of vaginismus are accompanied by an irritable condition of the blad- 
der, and that, as the terminal fibers of the hymen often extend from 
the meatus to the vesical neck, cystospasm may in these cases be due 
to reflex nerve irritation. An attempt to catheterize these patients 
is as liable to cause spasm of the bladder as an analogous attempt to 
examine the uterus would be to produce vaginismus. In these cases 
the hymen should be excised, and the vaginismus treated after the 
usual methods. 

Acute pelvic peritonitis and cellulitis cause great distress in many 
cases by their effect on the bladder. A constant desire to urinate, 
without the ability to make sufficient straining effort to accomplish 



FUNCTIONAL DISEASES OF THE BLADDER. 693 

the object, is verj often observed in all these acute pelvic inflamma- 
tions. Thedisturbance of the bladder is, of course, only a symptom 
of the primary and more important trouble, and simply requires to 
be mentioned here. The after-effects of pelvic peritonitis are what 
I especially desire to call attention to at present. 

The adhesions formed by the products of the inflammation of 
the pelvic peritonaeum are in some cases sufficient to prevent the 
normal filling of the bladder, and frequent urination then becomes 
a necessity. This derangement of function generally exists alone. 
The urine is retained without trouble up to a certain amount ; it is 
passed without pain, and no vesical tenesmus follows evacuation. 
Unless the contraction of the bladder is great, and the frequent 
necessity to urinate very troublesome, patients rarely consult a phy- 
sician for it. 

Paralysis of the bladder with retention may be caused by a pecul- 
iar condition of oedema, by which the detrusors are rendered power- 
less to act. It is usually caused by disease of the cervix uteri, para= 
metritis, or peritonitis. 



CHAPTER XXXIX. 

METHODS OF EXPLORATION OF THE BLADDER AND URETHRA, 

Preparatory to the study of organic diseases of the bladder and 
urethra, I desire to call attention to the methods and means of ex- 
ploring the bladder and urethra, and to some of the physical signs 
of disease obtained thereby. 

In all cystic affections the urine should be carefully examined, 
both chemically and microscopically. It is not necessary for me to 
describe the methods to be employed in this examination ; they will 
be found in the various books published on that subject. 

If an examination of the urine does not make the diagnosis clear, 
attention should be directed to a physical exploration of the bladder 
and urethra. For this purpose either a digital or an endoscopic ex- 
amination may be made. Digital examination per vaginam is one 
of the most valuable means of investigating the bladder and urethra. 
By this and by the bimanual touch the physical signs of many of the 
affections of these organs can be readily obtained. 

The method of making these examinations is exactly the sam_e as 
practiced in examining the uterus. The vaginal touch reveals the 
position of the bladder and urethra, the degree of their sensitiveness, 
the location of tenderness, if any is present, the increase or diminu- 
tion of elasticity, and the state of their walls, as regards thickening 
or irregularity. Distortions of the urethra from neoplasms or the 
products of inflammation can also be detected in this way. 

The bimanual touch will show whether the bladder is full, empty, 
or partially distended, and any foreign body of considerable size can 
be felt in the bladder in case the abdominal walls are not too rigid. 
As a means of detecting stone in the bladder of women, the biman- 
ual touch is the easiest, safest, and surest of all methods of explora- 
tion. The presence of neoplasms can be discovered in this way, 
although their composition can not be clearly made out. In some 
cases it is necessary to give an anaesthetic to relax the parts before 



METHODS OF EXPLORATION. 



695 



a satisfactory bimanual examination can be made. Tliere are many 
advantages gained in angestbetizing tbe patient wbile making a bi- 
manual examination, but some of the most im23ortant signs may be 
lost by the unconsciousness of the patient, such, for instance, as the 
location of tenderness. On that account I prefer in critical cases to 
make an examination both without and with ansesthesia. It is also 
well, when the object is to search for foreign bodies, like stone or 
tumors of any kind, to have a few ounces of urine in the bladder, 
unless that much gives the patient pain. The longer I practice the 
more I depend upon this method of examination. 

Another method of examination is by means of the endoscope. 
For this purpose I devised and have employed for years an endo- 
scope which has proved of great service. This instrument is com- 
posed of three parts. A glass tube {a, Fig. 226) is shaped like the 
ordinary test tube 
used by chemists, 
except that the 
mouth is a little 
more flaring. The 
second part (Z>, 
Fig. 226) is com- 
posed of two pieces 
— a mirror and its 
holder. A piece 
of very thin silver 
plate is made to fit 
nearly the whole length of the inside of the glass tube, and about 
one third of its circumference. To one end of this arrangement the 
mirror is attached at an angle of about 100°. At the other end a 
delicate handle projects at an obtuse angle. This part of the instru- 
ment looks like a section of a tube that has been divided into three 
equal parts by longitudinal section, with a mirror attached at one end 
and a handle at the other. This piece is made perfectly black on 
the inside, and answers two purposes — it holds the mirror, and, when 
placed in position for use, darkens one side of the glass tube. 

It will be seen that the mirror can be moved forward or back- 
ward, and turned around ; so that when the tube is introduced into 
the urethra or bladder, the exposed internal surfaces can be brought 
into view by moving the mirror while the tube remains stationary. 

Fig. 225, shows the glass tube placed inside of a fenestrated 
hard-rubber speculum ; and Fig. 227 shows the glass tube inside of 
a speculum that is open and beveled at the end. These specula are 




Figs. 225-227. — Skene's endoscope. 



696 DISEASES OF WOMEN. 

used in making aj^plications to the urethra and bladder, as will be 
described hereafter. 

The method of using this instrument is as follows : The tube, 
with the mirror inside, is introduced into the urethra, and bladder 
also if an examination of the lower portion of the latter be desired. 
Light is then thrown into the tube by the aid of a concave mirror. 
This shows that portion of the interior of the urethra or bladder 
which is opposite the mirror and in contact with the tube, and by 
moving the miiror backward and forward all the parts to be exam- 
ined are brought into view in regular succession. 

Sunlight may be used, and when it can be favorably controlled 
it answers better than any other method of illumination. It very 
often happens, however, that the light is insufficient. Dark, cloudy 
days, or the unfavorable position of the office-window, often make 
it impossible to employ sunlight for endoscopic examinations. On 
this account I prefer to use gaslight. For this purpose I employ a 
gas-bracket, which is movable in every direction, and which can be 
iixed in any position desired. By this means the light is easily ad- 
justed to the position of the patient on the examination table. An 
argand burner with the ordinary condensing attachment is used, 
which gives a very strong, yet soft, steady light. There is one ob- 
jection to the condenser, and that is the difficulty of getting the 
light in the exact place where it is needed. On this account I pre- 
fer the ordinary argand burner with the glass chimney, such as ocu- 
lists employ with the ophthalmoscope. 

The color of the mucous membrane lining the urethra and blad- 
der has already been described ; but it nmst be borne in mind that 
the endoscope modifies the color to some extent. This is especially 
so when examining the urethra. If a large-sized tube is used, the 
parts are put upon the stretch and the pressure of the glass on the 
mucous membrane interrupts the capillary circulation to some ex- 
tent, and renders the color as seen in the mirror a pale pinkish 
white. This when understood does not interfere with the examina- 
tion, as it only tends to make the contrast between the normal and 
the diseased tissues more marked. The only condition where the 
endoscope might lead to error is in acute general congestion of the 
urethra. The pressure of the instrument causes the congestion to 
disappear in part, and gives the idea that there is less hypersemia 
than there really is. In such cases I use the speculum or the ordi- 
nary endoscope (Fig. 227), and thereby remove all possibility of 
error. 

By a little practice in managing the light, sufficient dexterity to 



METHOD OF EXPLORATION. 69 T 

examine the urethra and neck of the bladder thoroughly and satis- 
factorily can soon be acquired. 

The cystoscope of Nitze and Leiter is the only instrument for 
thoroughly investigating the bladder. Bruck, of Breslau, first dis- 
covered the principles of the instrument, and Nitze and Leiter per- 

Wall of the bladder. 



Water-pipes. 
Fig. 227a. 

fected it. Dr. Willy Meyer gave a description of this instrument 
in " The l^ew York Medical Journal," April 21, 1888 : 

"The cystoscope (Fig. 227a) consists of a silver tube of the 
shape of a catheter, in the short beak of which a platinum wire is 
fastened. The latter is made incandescent by means of an electric 
current which passes through it, and then darts its rays upon the 
wall of the bladder through an oval window in the concavity of the 
beak, covered with transparent quartz. To convey the current of 
electricity to the platinum, an insulated wire runs through the whole 
length of the shank ; the metal of the tube forms the connection 
with the opposite pole. ^N^o cold water current is needed. Accord- 
ing to Mtze's design, a telescope is introduced into the shank of the 
cystoscope. It enlarges and magnifies the spot coming into sight. 
Without this telescope we should not see much more at the time 
than a spot about the size of a pea ; with it we are enabled to in- 
spect a portion as large as a silver dollar, and even more. 

" At the junction of beak and shank, corresponding to the con- 
cave side, a rectangular prism is cemented in, the hypotenuse-plane 
of which acts as a mirror on account of the total reflection of the 
rays. Thus a diminished, inverted real picture arises in the shank 
of that wall of the bladder which is situated at a ric^ht anHe to the 
longitudinal axis of the instrument, and opposite the prism. It is 
again inverted by means of the lenses of the telescope, and thrown 
to the outer end of it, where the examining person looks at tlie now 
upright picture through the magnifying ocular of the telescope. 



698 



DISEASES OF WOMEN". 



" If the fundus of tlie bladder is to be inspected with this in- 
strument, it must be turned 180°, and its handle deeply depressed 
between the thighs of the patient, the latter being in the recum- 
bent (lithotomy) position — the best for examination with the cysto- 
scope. 

"This manipulation may sometimes be very painful. To avoid 
this, a second instrument (Fig. 227b) is made with the window for 




Telescope, 

Wall of the bladder. 
Fig. 227b. 




Water-pipes. 



the incandescent platinum on the convex side of the beak. There 
is another window at the end of the straight tube through which 
the observer looks with the telescope. Of course, there is no prism. 
'' Leiter's cystoscope shows the old pattern with the improvements 
mentioned. A key near the handle can be made to make or break 
the current by turning to the right or left upon or from an ivory 
plate. The shank of the instrument is somewhat short ; its telescope 
diminishes the part in view a trifle." 




Fig. 227c. 

Before using the cystoscope, tlie beak should be put in water, 
and the light tested to see that it is in working order. Glycerin 
should be used to lubricate the instrument. The bladder must be 
washed, provided the urine is bloody or cloudy with mucus, and 
then be partially distended with from five to six ounces of clear 
water. If the urine is quite clear, no preliminary washing is neces- 
sary. 



METHODS OF EXPLORATION. G99 

W. Donald Napier has invented a probe that is of use in detect- 
ing foreign bodies in the bladder. No dilatation of the urethra is 
needed for its use. It consists of a beaked sound, the vesical end 
of which is covered with pure metallic lead. This, having been care- 
fully polished with soft leather, is dipped into a one-per-cent solu- 
tion of nitrate of silver, which gives it a beautiful black coating. 
Before use it should be carefully examined with a lens to see that 
its surface is perfect. When introduced into the bladder, if any 
hard body be present, such as a calculus, against which it strikes, an 
obvious impression is made upon the polished surface. 

Exploration of the bladder by dilatation of the urethra is a most 
valuable means of diagnosis. It may be employed in various de- 
grees. The urethra may be enlarged only sufficiently to admit a 
fair-sized endoscopic tube, or it may be dilated sufficiently to admit 
the finger. I will first give the methods that are commonly in use, 
and then explain the plan I usually adopt. Although there are rec- 
ords of bloodless dilatation of the urethra as far back as 1502 (Beni- 
vienni), 1506 (Marcus Sanctus), and 1561 (Franco), up to a late date 
the operation was not a common one. Franco used an instrument 
of his own for effecting dilatation. In the early part of the present 
century, dilatation by means of the compressed sponge and Weisse's 
metal dilator was somewhat used, but more for the extraction of cal- 
culi and foreign bodies than for purposes of diagnosis. 

To Simon, however, belongs the honor of improving the means 
employed, and introducing the subject to the profession. His 
method is this : He makes a single incision superiorly, or two slight 
lateral ones, in the wall of the meatus, about one tenth of an inch 
in depth. He also snips the urethro-vaginal septum to the depth of 
about one fifth of an inch. This is done to relax and prevent irregu- 
lar tearing of the meatal portion of the urethra, which is the most 
rigid and undilatable part of the canal. 

He next introduces a hard-rubber speculum, shaped somewhat 
like a cone, the cut end of which is protected by a rounded piece of 
wood within. His largest speculum has a diameter of nearly one 
inch ; his smallest about one third of an inch. After the introduc- 
tion of the largest one, the finger can be readily passed into the 
bladder, and the whole of its interior explored, save the antero-later- 
al portion, which is high up, and difficult to reach. The narrowest 
urethra may in this manner be sufficiently dilated in from five to ten 
minutes. 

Simon found that, without any bad results following, an adult 
woman could bear the introduction of a speculum having a circum- 
46 



700 



DISEASES OF WOMEX, 



ference of two and a half inches, and, when the necessity for marked 
dilatation was urgent and possibly resulting incontinence of com- 
paratively little importance, a cone having a circumference as high 
as two and eight tenths inches might be employed. 

In girls, specula having a circumference of from 1-88 inch to 
2-52 inches may be used. For most diagnostic and therapeutic pur- 
poses, instruments not large enough to produce incontinence are usu- 
ally sufficient. 

Winckel has used Simon's method seven times, and has had ex- 
cellent results ; and he says that, although the incisions made at the 
meatus are sometimes opened still further, and that a fresh one may 
appear under the clitoris, it is of little moment, as the presence of 
the dilator stops all haemorrhage, and the incisions heal readily. In 
none of Winckel's cases, although he w^atched them for weeks, was 
there any incontinence. Heath, in digital dilatation, found usually 
a tearing of the mucous membrane under the pubic arch, and incon- 
tinence was generally present for at least twenty-four hours. 

Instead of incising the 
meatus, I generally dilate it 
slowly, using for this pur- 
pose the bivalve urethral 
speculum (Fig. 228). When 
used as a dilator, I cover the 
blades with a piece of soft- 
rubber tubing. 

Isotwithstanding the testimony to the contrary, I am sure that 
dilatation of the urethra to any great extent is dangerous. There 
is danger of lacerating the urethra and causing incontinence, which 
can not be easily cured. Great care should therefore be exercised 
in dilatation, and it should not be resorted to at all unless there is 
some marked indication for it. 

In cases where extreme dilatation of the urethra does not prove 
sufficient for the desired end, the method of opening into the blad- 
der through the vaginal wall, as recommended by Simon, may be 
tried. He makes an incision from right to left into the anterior 
vaginal wall just in front of the os uteri. From the center of this 
incision another is carried forward about one inch in length in the 
line of the urethra, thus forming a T-incision. Fine tenacula are 
then fastened into the bladder-wall through the incision, and, with 
one hand pressing the abdomen, and by traction on the tenacula, the 
bladder is pulled down through the incision and opened. After all 
necessary procedures are completed, the edges should be carefully 




Fig, 228. — Bivalve urethral speculum (Skene). 



METHODS OF EXPLORATION". 701 

secured by sutures, and the parts will heal kindly. The bladder-walls 
coapt readily and accurately. 

It will be understood that this important operation is only to be 
performed for the purpose of detecting and removing foreign bodies 
and abnormal growi;hs from the bladder, and possibly to close vesico- 
intestinal fistulifi. 

Eapid dilatation of the urethra is chiefly useful for the purpose 
of allowing the extraction of foreign bodies and moderate-sized cal- 
culi, for cauterizing the mucous membrane, for opening hsemato- 
celes (Spiegelberg), for allowing the introduction of endoscopic tubes 
of large size in diagnosticating cystitis, calculi (vesical and ureteral), 
ulceration, vesico-intestinal fistula, polypi, and papilloma, and for the 
local treatment of these. 

Incision into the bladder, on the other hand, is useful in cases 
where calculi or other bodies are too large for safe removal by the 
urethra, the removal of tumors situated high up anteriorly or antero- 
laterally, in operations of various kinds where the urethra precludes 
free movement and good illumination, as in sewing up large vesico- 
intestinal fistulse. I may observe, in passing, that, in performing 
operations through the incision, artificial light might be thrown into 
the bladder by means of a small curved endoscopic tube and concave 
mirror in the urethra. 

In cases of cystitis and vesical ulceration, this operation has been 
performed by Sims, Emmet, Bozeman, Simpson, Hegar, and Simon, 
to prevent the stagnation and decomposition of urine in the diseased 
organ. 

Catheterization of the ureters has been performed by Simon and 
Winckel, but, as it is dificult, not without danger, and of little prac- 
tical value, I shall not dwell upon it here. 

In connection with the subject of physical exploration, I give 
here a list of the various instruments that I find of use in examin- 
ing and operating upon the bladder and urethra. They are as fol- 
lows : 

Two Skene's Sims's specula. 

One Folsom's speculum (modification). 

One Skene's reflux catheter for urethra. 

Two silver probes. 

One sponge-holder (steel). 

One knife. 

One Blake's polypus-snare (ear). 

One Allen's polypus-forceps (ear). 

Two glass pipettes, six inches long. 



702 DISEASES OF WOMEN. 

Two liead-mirrors on same strap, three and one half inches and 
one and one half inch. 

Skene's bivalve urethral specula. 

Ordinary urethral endoscopes, modified hj Skene. 

Two rectal endoscopes (long and short), wdth fenestrated rubber 
specula. 

Three urethral endoscopes (Xos. 13, 15, 17, American), with bev- 
eled rubber specula. 

Two beveled urethral endoscopes (^N'os. 19, 21, American), with 
fenestrated rubber specula. 

One brush for cleaning endoscopes. 

Having described the important methods to be employed in phys- 
ical exploration of the bladder, I now pass to a consideration of the 
organic diseases of the bladder and urethra. 



CHAPTER XL. 

ORGANIC DISEASES OF THE BLADDEE. 

Having treated of the methods of physical exploration of the 
bladder and urethra, I now invite attention to the organic diseases 
of these organs, and shall first describe those which affect the blad- 
der. These may conveniently be divided into three classes : 

I. Inflammatory ; II. I^on-inflammatory ; and III. l^eoplasms, 
hyperplasia, and atrophy. 

I, Inflammation of the Madder^ or cystitis : 

Under this head I shall include all forms of deranged nutrition 
which produce disorders of function, temporary or permanent lesions 
of structure, and the morbid material known as the " products of in- 
flammation." 

"Well-defined typical inflammation presents during its course cer- 
tain peculiarities which are characteristic of the affection, and with- 
out the existence of which the disorder can not be called true in- 
flammation. Inflammation, however, varies in character with the 
tissue or organ involved and the extent or intensity of the disease ; 
and, while there is really but one process of inflammation, as that 
process is often interrupted, prolonged, or modified in various ways, 
its products must necessarily vary greatly. 

Its divers grades or forms are distinguished as acute, chronic, 
catarrhal, interstitial, suppurative, croupous, diphtheritic, and gon- 
orrhgeal. 

Before entering upon the consideration of cystitis in its many 
forms, I desire to speak of hypergemia and haemorrhage of the blad- 
der. This latter affection might more properly, perhaps, be consid- 
ered under another head, but it is so closely connected with hyper- 
semia and inflammation that I prefer to treat it here. 

Hypersemia. — In all cases the first perceptible departure from the 
normal is a derangement of circulation. Hyperjemia of the mucous 
membrane is observed, and with it disorders of innervation, as is evi- 
denced by derangement of function and sensation. 



T04 DISEASES OF WOMEN. 

In lijpersemia of the mucous membrane of the bladder the blood- 
vessels are distended, and, becoming prominent and apparently more 
numerous, give to it a bright-red color. The arteries are the first 
to be affected. If the hvpersemia is not marked, or is produced bj 
some transient cause and not aggravated, it may pass off in a short 
time, and leave the membrane in its normal condition. If it is of a 
high grade, however, rupture of some of the vessels may occur, the 
haemorrhage taking place either on the free surface of the membrane 
or beneath its epithelial layer. Should this condition continue, the 
hypersemia which began in the arteries extends to the venous side of 
the circulation, and the vessels become more prominently and uni- 
formly distended. The congestion may also begin on the venous 
and extend to the arterial side, as in sudden interference with portal 
circulation. As a rule, however, it begins in the arteries. 

A clear distinction must be made between the acute congestion 
of which I am now speaking, and which is chiefly confined to the 
smaller vessels, and passive congestion with a varicose or hsemor- 
rhoidal condition of the veins about the neck of the bladder. This 
hsemorrhoidal condition I will speak of later. 

Symptomatology. — The symptoms of acute congestion of the 
bladder, as a rule, occur suddenly. Frequent but painless urination 
is the principal symptom. There is often a sense of heat and heavi- 
ness in the region of the bladder, which is greatly aggravated by 
standing or walking. When the urethra is involved, the patient 
complains that the urine "scalds" her. 

The general system is not disturbed — i. e., the pulse and tempera- 
ture remain normal. The physical signs are mostly negative. The 
composition of the urine is unchanged, save that there may be an 
excess of mucus and a few blood-globules present. There may be 
some tenderness on pressure over the bladder. The endoscope (when 
there is an opportunity to use it, which is very rare in this trouble) 
shows an increased redness of the mucous membrane, with occasion- 
ally an excess of mucus on its surface. 

Diagnosis. — The diagnosis has to be made by exclusion, the nat- 
ural history of the affection having in it nothing pathognomonic. 
It is liable to be confounded with sympathetic or other functional 
derangement of the bladder, caused by sudden dislocations of the 
uterus or by pelvic inflammation, such as pelvic peritonitis and its 
results. The former can be excluded by an examination of the pel- 
vic organs, and the latter by the constitutional symptoms of inflam- 
mation and the signs of such pelvic disease. 

Causes. — The causes of hyperemia of the bladder are exposure 



ORGANIC DISEASES OF THE BLADDER. 705 

to cold (especially during the menstrual period), wetting the feet, 
overtaxation in walking or using the sewing-machine, excessive vene- 
real indulgence, constipation of the bowels from torpor of the portal 
circulation, the excessive use of stimulants, and the use of improper 
articles of food. 

Treatment. — The treatment should be directed to equalizing the 
circulation. Diaphoretics, warm, stimulating foot baths, hot applica- 
tions over the epigastrium, and, above all, rest in the recumbent 
position. If the bowels are confined, tbey should be emptied by 
saline laxatives. When there is much irritation of the bladder, caus- 
ing frequent urination and vesical tenesmus, pulv. doveri with cam- 
phor should be given, or suppositories of belladonna and morphine 
introduced into the vagina. Under this treatment the trouble will 
usually pass off in a short time. It may, however, go on to the de- 
velopment of cystitis. 

Occasionally bleeding occurs in active or acute congestion of the 
bladder, and that leads me to speak of heemorrhage from the 
bladder. 

Haemorrhage from the Bladder. — Hgemorrhaga from the bladder, 
or (if I may be allowed to coin a word) cystorrhagia, is usually due 
to some important disease of the bladder, and is, therefore, rather a 
symptom than a disease. For this reason I will at present confine 
my remarks to haemorrhage when caused by acute congestion, w^hich 
I have just considered, or to varicose veins of the bladder. 

The bleeding may take place from the free surface of the mucous 
membrane, and mingle at once with the urine or coagulate in the 
bladder. It may also take place beneath the surface of the mucous 
membrane, and form ecchymoses, like the spots seen beneath the 
skin in purpura. We may also have a condition known as hemo- 
globinuria, in which only the coloring matter of the blood is found 
in the urine ; in such a case w^e should, of course, find no blood-cor- 
puscles. 

The quantity of blood varies greatly in different diseases, and in 
the same disease in different persons. In congestion of the bladder 
blood- globules will often be found in the urine only on microscopic 
examination, while at other times the urine will have the appearance 
of being all blood. Again, the blood may coagulate, and be passed 
in clots, or the coagula may remain in the bladder, finally break 
down, and be passed as a chocolate-colored or blackish matter. 

Symptomatology. — The symptoms of haemorrhage do not differ 
from those of congestion or the onset of cystitis, except when small 
clots form, distending the urethra, and causing pain in urinating. It 



706 DISEASES OF WOMEX. 

is very rare that bleeding from these causes is sufficient to prostrate 
the patient. 

As bleeding may take place at any point in the urinary tract, it 
is important always to locate the haemorrhage. When coming from 
the bladder in any quantity, it is usually passed in small clots, and 
is seldom so intimately mixed with the urine as when it comes from 
the kidneys or ureters. This statement is not exact, and at best 
gives but a probable idea of the true facts. To complete the diag- 
nosis, we nmst resort to something more trustworthy. Sir Henry 
Thompson gives a very ingenious method for determining as to 
whether pus found in the urine comes from the kidneys or bladder, 
and Van Buren and Keyes advise the same plan for detecting the 
source of haemorrhage. 

The method is this : " A soft catheter is gently introduced first 
within the neck of the bladder, the urine drawn oU, and the cavity 
washed out very gently with tepid water. If the water can not be 
made to flow away clear, the inference is that the blood comes from 
the cavity of the bladder. If it will flow away clear, then the cath- 
eter is closed for a few moments, the patient being at rest, and 
the few drachms of urine which collect nmj be drawn off and exam- 
ined. The bladder is now again washed out, and if, after a single 
washing, the second flow of injection is clear, while the drachm of 
urine was bloody, the inference is again complete that the blood 
comes from one or the other kidney." 

When it is known that the patient has had no Iddney-disease, 
nor symptoms of renal calculi, the endoscope may be employed, and 
possibly the bleeding-point found. This has been done with the 
instrument which I have described, but one may fail to find it if it 
be high up laterally or antero-laterally, or be covered by a fold of 
the mucous membrane. 

Haemorrhage from the urethra might mislead, but is easily de- 
tected if it is remembered that in this case bleeding occurs between 
the acts as well as during micturition. It may also readily be dis» 
covered with the endoscope, provided the tube be not too large. 

Causation. — The causes of vesical haemorrhage, or cystorrhagia, 
are numerous. Congestion, varicose veins, villous cancer, lesions of 
structure, as in ulceration and sloughing of mucous membrane from 
injury or cystitis, and obstruction to, or interference with, the portal 
circulation. This may possibly explain the fact that haemorrhage 
occasionally occurs in those suffering from malaria. Perhaps the 
vesical haemorrhage occurring in the intense heat of summer in the 
tropics may be thus explained. In malaria the obstruction to the 



( 



ORGANIC DISEASES OF THE BLADDER. 707 

circulation tlirougli tbe portal system, acting as a predisposing cause, 
the intense congestion of all tlie internal organs during a chill or 
from exposure to cold would certainly tend to produce cystorrhagia. 

In purpura, the eruptive, typhus, and typhoid fevers, bleeding 
from the bladder may occur ; but, as it is there secondary to the 
main disease, nothing need be said about it in this connection. 

The most marked predisposing cause of cystorrhagia in women 
is a tendency to the hsemorrhagic diathesis, so common among chlo- 
rotic females. 

Treatment. — The treatment must largely depend on the cause. 
In all cases rest in the recumbent position should be insisted on. A 
large number of haemostatics have been recommended, and some of 
them, such as aromatic sulphuric acid, tannic and gallic acids, in 
moderate doses, are doubtless of some value. I have, however, de- 
pended chiefly on doses of opium sufficiently large to quiet the desire 
to urinate, and alkaline diluents to render the urine non-irritant, when 
it was found to be excessively acid. 

If tho bleeding-point or points can bs discovered with the endo- 
scope, applications of acetic acid, persulphate of iron, or nitrate of 
silver may be made. Great care must be taken in using these reme- 
dies, lest inflammation and ulceration of the bladder result. Nitrate 
of silver and strong acetic acid are more to be feared than the others. 

When the haemorrhage is so free as to excite fears of prostration, 
ice may be employed. Small smooth pieces should be introduced 
into the vagina at regular intervals as long as the patient can com- 
fortably bear it. Ice may also be applied to the hypogastrium. 

When the blood coagulates and forms a large clot in the bladder, 
it should be allowed to remain until it breaks dowm and comes away 
of itself. The experience of surgeons is that there is much more 
danger in attempting to remove the clot than in letting it alone 
There are two dangers in removing coagula from the bladder. Ono 
is, that doing so will almost certainly start the bleeding again ; and 
the other is liability to injure the bladder, and cause inflammation. 
Let the clots take care of themselves, keeping the patient quiet and 
comfortable (with opium, if necessary) until the coagula are disposed 
of. Lime-water has been recommended as a solvent of blood-clots 
by Dr. J. H. Ledlin, of Pittsfield, Illinois, and, in the case reported 
by him, and which is narrated with the cases of haemorrhage in this 
chapter, seems to have acted well. 

In one case of traumatic vesical haemorrhage that came under 
my care, a large clot formed in the bladder, and urination was com- 
pletely arrested. I was unable to determine whether the inability 



708 DISEASES OF WOMEN. 

to urinate was due to the presence of the clot or to loss of contractile 
power of the vesical walls from the injury. The patient suffered so 
much, however, from the pain caused bj retention that I was obliged 
to use the catheter. I employed the flexible instrument of Jaques, 
and, by carefully worming it in past the clot, I succeeded from time 
to time in drawing off enough of the urine and broken-down clot to 
relieve the lady until she was able to relieve herself. I w^as careful 
not to disturb the clot. 

Allusion has been made to varicose veins of the bladder, called 
by some haemorrhoids of the bladder. This condition is chiefly 
found in pregnant women, especially those who have borne several 
children. The cause is interruption of the venous circulation by 
pressure of the gravid uterus. The veins of the anterior vaginal 
wall, introitus vulvse, and labia, will often be found in the same 
condition. Occasionally prolapsus of the bladder wdll also be found. 

This affection gives rise to those symptoms of pelvic distress and 
frequent urination that are so troublesome in some pregnant women. 
It must be kept in mind, however, that the same symptoms may 
come from pressure which does not produce varicose veins. 

If it is found that the patient feels relieved to some extent m 
the recumbent position, and the urine is normal, this trouble maj 
be suspected, and, if the symptoms are sufficiently urgent, a local 
examination should be made, which will reveal a varicose condition 
of the vessels of the urethra and vaginal w^alls, and from this it may 
be inferred that the same condition exists in the bladder. 

If the diagnosis is still doubtful, the endoscope will aid in settling 
the question. 

This affection is relieved or passes off altogether after confine- 
ment, and the best that can be done usually is to give rest and try 
to make the patient comfortable until the end of her " term." 

Should the trouble continue after delivery, especially if there is 
cystocele or prolapsus of the bladder, much good may be done by 
restoring and keeping the organ in place. This can best be accom- 
plished by using the cotton pessary or a roll of marine lint packed 
loosely into the vagina, like a tampon. The patient can be instructed 
to use this herself. Attention should be given to the general health, 
and particularly to the condition of the bowels and portal circulation. 
Rest in bed, and the use of cool water as a vaginal injection, may 
also be of use. 

Should hsemorrhage occur from this condition of the veins, it 
may be treated as described in the discussion of that subject. 



ORGANIC DISEASES OF THE BLADDER. 709 



ILLUSTRATIVE CASES. 

Case of Haemorrhage of the Bladder ; Blood-clots dissolved hy Lime- 
water. — J. 11. Ledlin, M. D., Pittsfield, Illinois, in a letter to the 
" Medical Record," November 8, 1879, sajs : I have a patient, a man 
who for years has suffered greatly from hsematuria. The blood 
comes from the kidneys. At times the haemorrhage is very profuse, 
and clots the bladder. Heretofore I have always succeeded in wash- 
ing it out with a double current catheter. Last Saturday I was called 
to see him. He had lost a great quantity of blood, and was suffering 
very much from vesical tenesmus ; I passed my catheter, and injected 
a stream of water. All at once the stream, returning, would stop. 
By withdrawing the instrument I could start it again, but he insisted 
there was a foreign body in there. I must say that the previous day 
he had experienced excruciating pain along the course of the ureter ; 
1 suspected stone, and sounded him, but could not discover one ; 
still, my instrument touched something ; I repeated the washing out 
of the bladder until the water returned colorless. I then made up 
my mind that there was a clot, with the coloring matter washed out, 
and, recollecting your account of dissolving the false membrane with 
lime-water, I threw in one half pint of lime-water, allowing it to 
remain half an hour. When it passed off it resembled what you 
describe as the appearance of the false membrane after lying in lime- 
water. He also passed a large piece of fibrin, which had evidently 
been acted on by lime-water, although not sufficiently to dissolve it 
entirely. Had it not passed away, I am convinced another injection 
would have dissolved it entirely. He is now quite comfortable, all 
sense of a foreign body in the bladder having passed away. 

Haemorrhage from the Bladder due to Malarial Influence. — This 
patient was a lady of twenty-one, married two years, never pregnant, 
and of a slightly strumous constitution. For several days she had to 
urinate more frequently that usual. She then began to be restless at 
night. These symptoms developed into well-marked fever in the 
afternoon and first part of the night. With this came frequent urin- 
ation, with pain and hsemorrhage from the bladder. The blood 
came from the neck of the bladder evidently, from the fact that it 
was mixed with the urine, but was dark in color, as it would have 
been if from the kidneys. There was no blood passed after the 
bladder v>'as empty, as would have been the case if it came from the 
urethra. 

The temperature was 103° F. in the evening; normal in the 
morning. This continued for two weeks, at which time I gave qui- 



710 DISEASES OF WOMEN. 

nine, gr. x, in the morning. After the qninia, the fever and bleed- 
ing stopped, and did not return. She was for over a year well, then 
her trouble returned — that is, she had painful urination without haem- 
orrhage. I found the cause to be a polypoid growth, which looked 
like a wart, in the anterior wall of the urethra near the meatus. I 
removed it by snare, with the result of relieving her completely. 



CYSTITIS. 

This is a disease that is much more common among women than 
is generally supposed. It is necessary, therefore, to inquire carefully 
into the etiology, pathology, and therapeutics of this affection, which 
causes great suffering on the part of the patient, and taxes the high- 
est skill of the ablest surgeons. 

To the several forms, grades, or degrees of this disease various 
names have been given, such as acute, subacute, and chronic cystitis, 
cystitis mucosa (catarrh of the bladder), interstitial cystitis, peri- and 
epi-cystitis, croupous, diphtheritic, and gonorrhoeal cystitis. This 
medley of names should not be allowed to lead to confusion, but 
this fact should be iirmly fixed in the mind, that, with the exception 
of the last three (the etiology and pathology of which are somewhat 
different), they are all simply steps or stages in one general process. 
Thus a patient may have received an injury of the bladder by the 
use of a catheter, causing an acute cystitis. This may end in con- 
valescence, or merge slowly into the more chronic form, having very 
likely as an intermediate step catarrhal cystitis. This, too, may go 
on to recovery ; but, if the process extends, and its severity increases, 
ulceration takes place, and the submucous and intermuscular tissues 
become involved, producing interstitial cystitis. If the inflammation 
extends still further, and involves the serous coat of the bladder, 
either by extension or ulceration, with or without perforation, we 
shall have peri- or epi-cystitis. In this example I hope I have made 
clear the fact that names are only given to denote the degree of in- 
tensity of the inflammatory process, and the character and extent of 
the tissue involved. 

Inflammation of the mucous membrane alone is by far the most 
common form, and hence, in using the term cystitis, reference is 
usually made to inflammation of that membrane only. When other 
tissues are involved, or the character of the disease is peculiar, some 
qualifying word is added to distinguish it. 

Acute inflammation of the bladder, other than that due to local 
causes, is emphatically denied an existence by many authors. The 



ORGANIC DISEASES OF THE BLADDER. 711 

statements made are usually too broad and sweeping to be sustained 
by the facts observed in actual practice. I am inclined to believe 
that cases of acute cystitis from exposure to cold and wet do occur. 
It must, however, be admitted that such cases are very rare, and 
some that have been considered as acute idiopathic cystitis may have 
been but a development of acute inflammatory disease upon a pre- 
existing abnormal condition. 

It is also possible that those who deny the existence of acute idio- 
pathic cystitis may base their belief upon the fact that in what is 
called acute inflammation of the bladder all the phenomena of well- 
defined inflammation are not present, while others consider hyper- 
semia of the mucous membrane and derangement of bladder function 
all that is necessary to constitute cystitis. Thus tlie apparently dif- 
ferent opinions that exist among authors upon this subject may arise 
from conflicting views as to what really constitutes inflammation. 

I prefer to class this condition (of congestion, hypersecretion of 
mucus, abnormal exfoliation of epithelium, and irritability) among 
the inflammatory afllections, and call it acute cystitis. Such an afliec- 
tion as this is met with in every-day practice, and I know of no bet- 
ter name for it. 

With this understanding, then, I will pass to a discussion of 
acute cystitis. 

Pathology. — As acute cystitis soon terminates in resolution, or 
merges gradually into chronic cystitis, I think it best to give the 
pathology of both diseases at once, they being, as I have already said, 
simply different in degree of intensity and duration. 

The morbid anatomy of cystitis is the same as that of inflamma- 
tion of mucous membranes in other parts of the body. In the more 
acute forms the membrane is swollen and relaxed, and .of a bright 
or deep red color, from hypersemia. The surface is partially or en- 
tirely covered with a thick, tenacious mucus. There is exfoliation 
of the epithelium, as sliown by the partially denuded condition of 
the membrane, especially at the top of the rugge, and pus and 
loose cells are found in the sulci between the folds. 

In some instances, especially in cases of acute cystitis caused by 
extreme overdistention due to mechanical or other retention, there 
may occur a throwing off of the whole or only a part of the mucous 
membrane of the bladder. This is more apt to occur when the re- 
tention and overdistention are caused by various accidents of the 
puerperal state or during delivery. That the sepaiation of the 
mucous membrane is not due to direct injury caused by the child's 
head or instruments carelessly used, but to the effect of overdisten- 



712 DISEASES OF WOMEN. 

tion, is shown by the fact that the vesical neck, which is subject to 
the most direct injury, seldom shows separation of its mucous mem- 
brane. That injury to the organ may predispose to separation, or 
even determine it when abeady predisposed to it by some other 
cause, there can be no doubt. Most of these cases of separation of 
the mucous membrane have occurred in women, and almost all fol- 
lowed delivery. The bladder which has participated in the general 
congestion of the pelvic organs incident to the puerperal state is in 
an excellent condition to allow such separation to take place. 

The manner of its production is probably as follows : A woman 
at full term is delivered after a long and tedious labor, with or with- 
out the use of instruments, of a healthy child. The child's head or 
the forceps may have done violence to tlie urethral mucous mem- 
brane by crowding the urethi-a against the unyielding pubic bones. 
Swelling of the mucous membrane results, and retention of urine 
(if the patient be not relieved by the catheter) follows and persists 
for a varying length of time. The doctor, the nurse, and the pa- 
tient herself are often led to believe, from the constant or inter- 
mittent dribbling of urine, that there is an irritable condition of 
that organ, with frequent urination. The truth is, that this drib- 
bling (stilHcidium) is almost a certain sign of an overfilled bladder, 
and if the patient be not relieved the distention will gradually in- 
crease. The organ having reached its limit of distention, or being 
stretched to its utmost, the pressure within is so great as to cut off 
the supply of blood to the submucous tissue, and thus to the mu- 
cous membrane itself. This is more readily accomplished, as the 
muscular fibers are pulled apart and the mucous membrane thereby 
allowed a certain amount of bulging, by which its blood-supply is 
seriously interfered with. If the distention be relieved early 
enough, nothing worse than an acute cystitis results ; but if not re- 
lieved, partial or total death of the membrane occurs, and it is 
sooner or later thrown off. Although death of the membrane may 
not take place in every case, or in one half of the cases of overdis- 
tention, it is no argument against this method of its production. 
Nor yet is it an argument in favor of the idea that it is caused by 
instrumental violence to the body as well as the neck of the viscus ; 
for that the latter can not be the only cause may be seen from the 
fact that it has occuiTed in the male (List on per Eanies). It is 
probable that there are several causes, and that these may work to- 
gether to produce the result. From the uniform exfoliation it 
would look, however, as if the most important cause was a uniform 
pressure cutting off the blood-supply, and thus causing death of the 



OKGANIC DISEASES OF THE BLADDER. 713 

part. It is even to be conceived that where marked injury has been 
done the membrane by overdistention (though not sufficient in it- 
self to cause death), too rapid relief of retention causing congestion, 
irritation by catheter, peculiar systemic conditions, and the intense 
inflammation which follows may finish the work, viz. : fully carry 
out the impression already made by the overdistention. 

This affection is not a common one, and though cases may sel- 
dom be met 1 desire to lay stress upon the great importance of pay- 
ing strict and individual attention to the condition of the urinary 
organs in pregnant and parturient women. The catheter can tell 
more of the condition of the patient's bladder in such cases than any 
nurse, and can do no harm whatever when a soft instrument is used 
with care. 

Experiments on dogs have proved that the detachment of the 
membrane begins at that part of the bladder just opposite the vesi- 
cal neck. At this point the membrane bulges out with a collection 
of blood and serum beneath it, and this bulging gradually extends 
to other parts. Meantime, in the bladder, the mucus poured out 
to shield the membrane causes the urine to decompose, and incnista- 
tions of amorphous and tripla phosphates are found on the surface 
of the exfoliated membrane. The color of the mucous membrane is 
usually either a deep red, greenish red, or black, and it may come away 
either in pieces or as a whole. In some cases (Mr. Wells's second 
case, Barnes) part of the muscular as well as the mucous tissue 
sloughed off and came away. In Mr. Liston's case the entire 
mucous membrane came away through a supra-pubic opening made 
by that gentleman to relieve retention. This occurred in the case 
of a male adult. 

Some of these patients have recovered, and it is believed by 
Schatz that the reproduction of the membrane commences at that 
portion of it always left at the vesical neck. 

That the completion of the sloughing does not takes place until 
sometime after the injury is done, and that the membrane itself may 
block the urethra and cause further retention, is illustrated by the 
following case, taken from Barnes's able lecture in the " Lancet," 
January 2, 1875. The case was under the care of Dr. Wardell, 
at the Infirmary, Tunbridge Wells. " A woman was admitted 
with retention of urine. Fetid urine was drawn off. A foetus 
of three or four months was expelled followed by its placenta. 
Then incontinence ensued. The urine was still offensive, and 
loaded with mucus. Twelve days later she was seized with great 
pain over the pubic region. Next morning the house surgeon was 



714 DISEASES OF WOMEN. 

called to see her on account of excessive pain. He felt a substance 
being expelled, and saw a mass protruding tlirough the meatus uri- 
narius. This was expelled in half an hour. At the moment of ex- 
pulsion the urine gushed out in great force and in large quantity. 
Instant relief followed, and she perfectly recovered. The substance 
looked as if it were the whole mucous coat of the bladder. Its 
inner surface was coated with gritty deposits. Its minute structure 
is not described." Barnes has no doubt but that the retention was 
in this case caused by retroversion of the gravid uterus. 

One of Mr. Spencer Wells's cases, also cited by Barnes {loc. cii), 
is very instructive : " A woman, aged 22, had a natural labor with 
her first child. The bladder was not emptied for sixty-two hours. 
Five pints of turbid, bloody urine were then drawn off. Cystitis fol- 
lowed, then incontinence of urine, and a train of distressing cerebral 
symptoms, ending in death two months after delivery. The bladder 
after death was found to contain a detached cast, lying loose, cov- 
ered with gritty deposits of urates and phosphates. The walls of 
the bladder were thick and contracted, the muscular fibers being 
distinctly visible. The cast resembled degenerated epithelium. 
On boiling a piece of it in dilute acetic acid, much of the saline 
matter became dissolved, and some of the tissue became clear, look- 
ing like smooth muscular tissue which had begun to degenerate, as 
shown by the deposit of fatty or albuminous particles in its sub- 
stance." 

Further pathological results may follow the prolonged retention 
of urine. The bladder having reached a certain point where no 
more urine can enter it, and even before this time, the ureters are 
filled from the urine above, and as the renal pelves fill, both they 
and the ureters are put greatly on the stretch. The kidneys con- 
tinue to secrete urine until the pressure in the urinary tubules equals 
that of the blood in the glomerulu?. At that point all secretion 
ceases, and pressure on the emulgent veins becomes so great that de- 
generative changes are apt to take place. In some cases after the 
pressure is relieved, acute nephritis results. The urine following 
such a condition of distention is loaded with hyaline, granular, and 
epithelial casts, and epithelial elements from the kidneys. 

The following case, which occurred in the practice of Dr. Geo. 
W. Gushing, of this city (the doctor having kindly furnished me 
with a report of it), may serve as an illustration of what I have been 
saying : 

" Mrs. S., of I^ew York, aged twenty- six ; married eight years ; 
one child ; catamenia regular ; appetite fair ; bowels sluggish ; no 



ORGAOTC DISExiSES OF THE BLADDER. Y15 

dysuria pre\^ions to present attack. Has been under treatment for 
the past two months for cervical endometritis. Local applications of 
mild astringents and glycerin, with injections of borax. Tonics 
and laxatives internally. Theie being some tendency to tubercu- 
losis, she was given cod-liver oil. 

"I was called to see this patient May 29, 1877. She told me 
she was suffering from internal hgemorrhoids, and that the rectal 
tenesmus was very distressing. She had had similar attacks before, 
and seemed to have no doubt as to what the trouble was. As she 
was menstruating I made no examination, but advised rest and a 
laxative powder, to be followed by morphia suppositories. 

'^ May 30. — Bowels moved since last visit with considerable 
pain. Complained of some vesical irritation, but had passed urine. 
Not much relief. 

''''May 31st. — Xo better. An examination showed no haemor- 
rhoids. Menses ceased. Yaginal examination revealed a very sensi- 
tive spot, with hardening on the right side, between the rectum and 
vagina. Pulse and temperature slightly elevated. Yesical and rec- 
tal tenesmus, but no trouble in passing water. Made diagnosis of 
probable pelvic abscess. Advised poultices to the perinseum, warm 
applications over the abdomen, and gave anodynes. Patient much 
relieved by the treatment, but still having severe pelvic distress. 

'^ June 2d. — Condition the same. 

'''June 3d. — Found the vesical distress increased. Her husband 
said that she had passed urine during the night. Was called to her 
in the afternoon, and found her in great suffering. Said that her 
husband had misinformed me, and that she had passed no urine for 
about thirty hours. I examined the abdomen, and found dullness 
well up to the umbilicus. Introducing a catheter, I drew off a large 
quantity of very offensive, high-colored urine, with much relief to 
the patient. For the next two days I was obliged to use the cath- 
eter. An examination of the urine drawn off was made, and showed 
the presence of renal epithelium, granular, hyaline, and epithelial 
casts, and considerable albumen, as also epithelium from the bladder 
and ureters. 

" June 5t7i. — I found a tendency of the inflammatory products 
in the pelvis to point about the center of the perinseum, and, though 
not quite sure of pus, I punctured and evacuated quite a large amount 
of it. 

" Since then the treatment has been the use of alkalies and sooth- 
ing drinks — tr. ferri chloridi — and washing out the bladder with 
lukewarm water containing salt and a little carbolic acid. The al)- 
47 



716 DISEASES OF WOMEN. 

scess remaining open and very sluggish for some time, I put the 
patient under ether, and performed the operation for fistula in ano. 
At the present writing, October 30th, Mrs. S. is in excellent condi- 
tion, having gained in flesh and strength, and being no longer trou- 
bled with the vesical disorder." 

This case is not only interesting as showing the serious changes 
that may occur in the kidneys from vesical distention, but as illus- 
trating the occurrence of retention of urine from reflex nervous in- 
fluence. Abscesses about the rectum are especially prone to cause 
retention. Although in this case the mischief .done to the kidneys 
was soon corrected, it does not follow that it will be so readily 
accomplished in all cases, especially if the retention continues un- 
relieved for any length of time. 



CHRONIC CYSTITIS. 

Pathology. — In chronic cystitis the redness of acute inflamma- 
tion gradually gives way to a muddy gray color, the membrane being 
smeared in places with a dark yellow muco-purulent secretion. As 
the disease advances, there is excessive cell growth on the free mu- 
cous surface. Patches of ulceration appear here and there, attended 
with the formation of pus and occasional, though usually slight, 
haemorrhages. Sometimes, at the portions destroyed by ulceration, 
the process of hyperplasia is established, and a polypoid material is 
developed. This has the appearance of exuberant granulations, as 
seen on a healing sore. At other times, and even in portions of the 
same organ in which hyperplasia occurs, the process of ulceration 
advances. The submucous intermuscular tissue partakes of the 
inflammatory trouble, and thickening of the vesical walls results. 
The decomposed urine, mixed with pus, mucus, blood, and shreds 
of membrane, forming the chocolate-colored fluid found in the 
advanced stages of this disease, acts as an irritant on the unhealthy 
membrane, and produces deeper or fresh ulceration. 

In advanced cases, "^vitb deep ulceration, the muscular flbers 
(which resist the destructive processes longest) are occasionally seen, 
stretching from one side of an ulcer to the other, forming a sort of 
bridge. When the end of one of these fibers becomes detached, it 
floats like a filament in the contents of the bladder. In some cases 
the salts of the urine are deposited, and form incrustations on the 
ragged mucous membrane. 

I remember that one of my patients frequently passed lumps of 
material that on examination proved to consist of all tliese products 



ORGANIC DISEASES OF THE BLADDER. 71 7 

of destructive inflaramatioTi, among which were mixed deposits of 
the urinary salts in the form of hard, gritty particles. 

In cases of long standing, the vesical ends of the ureters are 
obstructed by swelling and hypertrophy of the bladder- walls. This 
produces obstruction to the free flow of urine, and leads to dilatation 
of the ureters and renal pelves, and in some cases organic disease of 
the kidneys follows in the train of pathological sequences. I will 
refer to this subject again. 

When the disease has destroyed the mucous membrane partially 
or wholly, and extends to the muscular parietes, we have what is 
known as interstitial cystitis, and, if the serous coat becomes in- 
volved, there is also pericystitis. This latter is simply an inflam- 
mation of that portion of the pelvic peritongeum which covers the 
bladder. In interstitial cystitis, after destruction of portions of the 
mucous membrane by ulceration, the areolar tissue beneath it and in 
the muscular walls gives way, the muscular fiber generally becomes 
thickened and burrowed by ulcerated cavities, irregular in form, and 
surrounded by cicatricial tissue. The extreme hypertrophy of the 
muscular coat found in the bladder of the male under these circum- 
stances does not so commonly exist in that of the female. 

In epi- or peri-cystitis the peritoneal coat is found to be hyper- 
semic and thickened by exudation, and the adhesions which follow 
bind together the bladder and the neighboring organs. Perforation 
of the peritonaeum sometimes occurs, allowing infiltration of the 
urine. This usually develops general peritonitis or septicaemia, or 
both, and death almost inevitably follows. 

I have already stated that the walls of the bladder, including the 
serous coat, may become involved by the extension of a primary 
inflammation of the mucous membrane. This is undoubtedly the 
usual mode of occurrence, but, in some cases, I think that all of the 
bladder coats may become inflamed at the same time, making an 
inflammation in toto. At least, it is a fact that in some cases the 
mucous, muscular, and serous layers of the organ in question become 
involved in such rapid succession as to prevent us from detecting its 
progress from one tissue to another. 

The inflammatory process, having traversed the mucous and mus- 
cular coats, and involved the serous, especially where ulceration of 
the mucous membrane accompanies it, is likely to extend to the 
other portions of the pelvic peritonaeum and cellular tissue if the 
patient lives sufficiently long. 

It will be observed that in this condition there is about the same 
pathological anatomy as in pelvic peritonitis and cellulitis where in- 



718 DISEASES OF WOMEK 

flammation of the bladder-walls is caused bj, and consequently sec- 
ondary to, the pelvic inflammation. In such condition the kidneys 
and ureters are usually found diseased. In some cases the cellular 
tissue about the bladder becomes greatly increased, and occasionally 
abscesses form, as in ordinary pelvic cellulitis. 

I am satisfied that the disease described in some of the text-books 
as idiopathic pericystitis is, in almost all cases, when it occurs in 
women, a pelvic peritonitis originally, the bladder becoming aiFected 
secondarily. 

One of the most serious results of intense vesical inflammation 
is gangrene. The bladder becomes distended from paralysis of its 
muscular walls, and its contents are found to be a brownish colored 
fluid, consisting of decomposed urine, shreds of broken-down mucous 
membrane, altered blood, pus, epithelial elements, and urinary salts. 
The mucous membrane is found to be soft, pultaceous, and altered 
in color, the latter varying from a deep, charred black to a dark 
greenish or greenish yellow. 

The submucous connective-tissue layer and the muscular coat are 
softened, discolored, and infiltrated mth malodorous pus. The peri- 
tonaeum is also injected, and in places discolored, sometimes per- 
forated, and having undergone fatty degeneration. This complica- 
tion usually occurs in the coarse of chronic cystitis with considerable 
ulceration, and in which an acute inflammation is lighted up, 
there not being sufficient vitality left to prevent rapid and deep 
gangrene. 

These extreme forms of cystitis are rare, and occur generally in 
connection with abnormal cases of labor. A pregnant woman having 
a cystitis of a mild form is liable to develop acute general cystitis 
at her confinement. Again, inflammation and gangrene of the blad- 
der sometimes follow instrumental or manual delivery in which 
severe contusions of the bladder have occurred. 

I desire now to call attention to some of the effects of cystitis on 
the ureters and kidneys. That form of vesical inflammation known 
as chronic cystitis may travel up the ureters to the kidneys, produc- 
ing ureteritis, pyelitis, pyonephrosis, or renal abscess. This affec- 
tion seems more commonly to attack the left ureter and kidney. I 
say seems^ that being simply my opinion, derived from the cases 
that I have seen or of which I have read. I know of no statistics 
upon the subject. This complication is not so common in females 
as in males, which is owing, perhaps, to the fact that their short ure- 
thra, being, as a rule, free from stricture, and seldom obstructed 
otherwise for any length of time, the inflammation of the bladder 



ORGANIC DISEASES OF THE BLADDER. 719 

has less tendency to extend, is less severe, and, as a rule, is earlier 
and more easily treated locally than in the male. 

It can not be denied that the damming back of urine into the 
ureters and renal pelves is a factor in the production of disease in 
these parts. Suppose that an inflamed ureter becomes blocked up 
from any cause (a mucous, purulent, or blood plug ; by the impaction 
of a small calculus from the kidney ; thickening of its mucous mem- 
brane ; or hypertrophy of the bladder-walls), the urine behind the 
point of obstruction greatly distends the ureter and renal pelvis, de- 
composes, and produces acute pyelitis, which often leads to destruc- 
tion of the kidney on that side. 

In post-mortem examinations of such cases it will be found that 
the mucous membrane of the dilated ureter and pelvis of the kid- 
ney is swollen, pulpy, and of a dirty-drab, grayish, or greenish color, 
and possibly with incrustations of saline matter upon its surface. 
The renal pelvis may be sacculated, and the pouches may contain 
shreds of membrane, thickened, dirty pus, and saline matter. The 
kidney, when free from organic lesion, is always sympathetically 
affected, being enlarged and congested. Abscesses of the kidney 
itself have been found in these cases. 

The inflamed and dilated pelvis of the kidney, gradually enlarg- 
ing, flattens out, and implicates the papillse, and later the pyramids 
in the inflammatory process, until, finally, the whole organ is con- 
verted into a sacculated abscess. 

When there is destructive inflammation of the kidney (the ureter 
not being obstructed, and the pus having a free exit), the organ 
shrinks until it is converted into a little shriveled body, weighing 
from a few drachms to an ounce or two. If the purulent matter has 
not free exit, it fills the kidney, and becomes thick and putty-hke, 
cutting like fresh cheese. This may be the case where the purulent 
matter can not or does not escape from the kidney, the ureter being 
perfectly free throughout. The septa between the sacculi are occa- 
sionally calcified. 

The pyramids alone may suffer, their tissue being converted into 
purulent matter, the whole having the appearance of soft putty, in 
some cases studded with calcareous masses. When the purulent 
matter is washed out, the hole left looks as though the pyramid had 
been punched out, so smooth and clean cut are its edges. 

Again, the kidneys may be studded with minute abscesses. 
Where one kidney is wholly or partially destroyed, the other, if 
healthy, is, as a rule, largely hypertrophied. 

In some cases of long standing the affected kidney does not brealv 



720 DISEASES OF WOMEN. 

down into purulent matter, but by a slower process, probably that 
of chronic congestion, becomes granular and contracted. 

The study of the renal complications of cystitis is a very interest- 
ing and instructive one, but it is too extensive to permit of anything 
like a full discussion here. For a more elaborate consideration of 
the subject, I must refer to the special books on renal diseases. 

Sym]?tomatology. — The various forms of cystitis being simply 
stages of the same disease, I shall speak of their symptoms all under 
one head. 

They may, for convenience sake, be divided as follows : 

1. Symptoms referable to the organ or its contents. 

2. Symptoms referable to neighboring organs, that suffer either 
from sympathy or through direct extension. 

3. Symptoms referable to various conditions of the general sys- 
tem, as : {a) The vascular system, ih) The digestive tract, (c) The 
cutaneous surface, {d) The nervous system — cephalic and sub- 
cephalic. 

1. The symptoms referable to the organ itself are chiefly de- 
rangement of function — viz., pain, tenesmus, and frequent nrination. 
The symptoms vary in severity according to the extent and intensity 
of the cystitis. In the mildest form of tlie trouble there is frequent 
desire to pass water, which often comes with unusual force. Mic- 
turition is followed by a desire to strain, called vesical tenesmus, as 
if the organ had not been fully emptied. In the more acute cases 
this gives rise to the most intense agony, the patient remaining on 
the vessel for hours at a time. The sensation of a few drops of urine 
remaining in the bladder may pass off in a few moments, but, as a 
rule, returns after each micturition. 

As the disease advances, and ulcerative changes take place, this 
vesical tenesmus returns in full force, and the powerful squeezing 
together of the bladder- walls during and after urination produces 
intense pain. Sometimes pains shoot up into the breast or the re- 
gion of the umbilicus. There is often a dull, heavy aching in the 
perinseum. In nearly all cases there is continuous backache, or, more 
correctly, sacral pain. These pains seem to be most severe in cases 
of long standing, where, upon an already ulcerated surface, an acute 
inflammation is set up by errors in diet, medicines, violence in cath- 
eterization, rapid changes in temperature, and the weather. 

The condition of the urine in acute or chronic cystitis is of im- 
portance, but if reliance is placed upon it alone for a diagnosis there 
wall be many disappointments. The specific gravity is usually low 
in the more chronic types, varying from 1*005 to 1*018, being asu- 



OEGAXIO DISEASES OF THE BLADDER. 721 

Qallj about I'OIO. In the primary acute form the gravity is little 
if anything below the normal, and, if there is marked fever, may 
rise as high as 1*030. In acute attacks engrafted on a chronic state, 
the gravity is usually low. When the specilic gravity is low in acute 
cystitis, if not dependent on the diluent drinks and diuretics given, 
it is probably due to a slight sympathetic hypersemia of the kidneys. 
The low gravity in chronic cystitis is possibly due to the same cause, 
and a urine not only proportionally but really deficient in the urin- 
ary salts is excreted. To this may be attributed many of the ursemic 
(ammonsemic) symptoms accompanying the disease, which are sup- 
posed by many to be due to absorption of decomposed nrine. That 
such absorption might take place after ulcerative processes had be- 
gun, or even slight epithelial erosion had taken place, there can be 
no doubt; but it is a question whether we are to look to the absorp- 
tion from the eroded bladder as the only method of their production. 
I shall speak of this more fully very soon. 

The reaction of the urine in acute cases, when the affection is 
not due to, or accompanied by, retention, is at first usually acid. If 
there be retention, the reaction is usually alkaline, due partly to the 
fixed alkali of the mucas which is present in excess, but chiefly to 
the ammonia disengaged in the breaking down of the urea. In 
chronic cystitis the reaction is almost invariably alkaline, being in- 
tensely ammoniacal. 

In the primary acute form, the color is but slightly altered. 
The presence of a little blood may give to the urine a smoky tint, 
and if decomposed it will look hazy and perhaps contain sparkling 
crystals of the triple phosphate. In the chronic form the urine is 
of a pale, dirty yellow hue, and may be of a deep red from the 
presence of considerable blood. 

The odor is ammoniacal in the acute type, if the urine be de- 
composed, otherwise it is normal. In the chronic form it has not 
only an ammoniacal but a peculiar pungent odor of flesh. This is 
usually known as organic^ from the fact that it is due to the amount 
of organic material present. 

The sediment in acute cystitis is usually mucus, sometimes pus 
(white and clinging to the bottom, or somewhat flocculent). It may 
be tinged with blood, or rendered denser and whiter from the pres- 
ence of the amorphous and triple phosphates. In chronic cystitis 
the sediment is commonly heavy, and of a dirty brown or brownish 
yellow color. Flakes of pus, shreds of tissue, as well as blood and 
epithelial elements, cause it to vary greatly in different cases. 
When the intense alkalinity of the urine has rendered the pus gelat- 



722 DISEASES OF WOMEN". 

inous, the sediment is seen as a ropy mass that chngs tenaciously 
to the bottom of the vessel when inverted, or slides about in a jelly- 
like mass. 

jyjcroscopically, this sediment presents a varied and interesting 
appearance. In the acute form numerous fibrillge of mucns, a few 
pus-corpuscles, and possibly blood-globules are to be seen, and if de- 
composition has taken place, the amorphous and triple phosphates. 

In chronic cystitis pus-corpuscles ai'e usually present in large 
amount. There is also a varying amount of mucus, triple and amor- 
phous phosphates, spheres of the urate of ammonia, organic debris^ 
and in some cases epithelial elements. In the advanced stages of 
chronic cystitis e^Dithelial elements of any kind ai-e very rarely found. 
It is only in the earher stages that normal and transitional forms of 
vesical epithelium ai-e present. Even then dependence must not be 
placed upon that alone in making a differential diagnosis, lest a pye- 
litis may be mistaken for a cystitis, or vice versa ; the transitional 
forms of epithelium from tlie bladder closely resembhng the nor- 
mal epithelium from certain other parts of the urinary tract. The 
return to a healthy condition is marked by the disappearance of pus ; 
the reappearance of epithelium in the urine, first transitional, then 
perfect ; while the products of inflammation decrease in amount and 
finally disappear altogether. When there is sympathetic congestion 
of the kidnevs, small lio-ht OTanular and hvaline casts mav be found. 
If organic renal disease is present, large, small, and medium-sized 
hyaline, light and dark granular, and pus casts will be found, as 
also epithelial and blood casts. In some cases, where extensive de- 
structive change has taken place in the kidneys, no evidences are 
found in the urine, either during its progress or after its completion. 

Upon testing the urine chemically, albumen will be found in 
proportion to the amount of pus or blood present. If renal disease co- 
exist, the amount of albumen will be greatly increased. In chronic 
cystitis without renal disease the amount of albumen in a number 
of cases studied varied from one sixteenth to one fiith of the bulk 
of urine. There is usually a real excess of both fixed and volatile 
alkaline salts, as also of the earthy and alkaline phosphates and the 
chloride of sodium. 

In the advanced stages, where there is a depraved condition of 
the blood, urohaematin is present in a marked degree, and urea is 
either somewhat or decidedly diminished. In other cases, and at 
first, the urea may be present in normal amount. 

2. Symptoms Referable to Neighboring Organs. — These are not 
especially marked. In some cases, with the intense vesical tenes- 



ORGANIC DISEASES OF THE BLADDER. 723 

mus, there may exist an irritable condition of the rectum, with some 
tenesmus and pain at stool. 

The uterus is often congested, which causes a free leucorrhoea ; 
subinvoKition often occurs after the confinement of those who have 
had cystitis during pregnancy. Extension of the inflammation in 
extreme cases may cause metritis and pelvic cellulitis and perito- 
nitis. The symptoms thus arising will be characteristic of the dis- 
ease of the organs or tissues involved. 

Menstruation may be variously disturbed ; menorrhagia, metror- 
rhagia, or amenorrhoea resulting either from congestion^ inflamma- 
tory extension, or reflex nervous influence. 

Neuralgia of the uterus or ovaries may also be produced in this 
way. I have just said that subinvolution of the uterus is almost 
sure to follow a pregnancy occurring during the existence of a 
chronic vesical inflammation, and I am inclined to believe that the 
same result is produced in some cases by an acute cystitis following 
delivery. 

Renal disturbances upon which I have already touched will be 
spoken of more at length hereafter. 

3. Symptoms Referable to Disturbances of the General System. — 
These symptoms may be dae to reflex nervous influence, or to di- 
rect blood-poisoning. For convenience sake I will first consider : 

{a) The Vascular System. — Although there has been much dis- 
pute among authors as to how and by what tiie general poisoning is 
caused, there seems to be no question as to whether such a poison- 
ing really does take place. As general systemic efliects may be pro- 
duced by two separate blood conditions, I will discuss the subject 
under two heads, prefacing their consideration, however, with the 
remark that, as a rule, the two conditions exist together. They are : 
first, abnorm^al ingredients existing in the blood ; and, second, a poor 
condition of the blood itself (angemia). 

The poisoning of the general system that usually complicates 
cystitis of long standing may be produced in three ways, viz : 

1. Organic renal disease, or renal hypersemia (sympathetic), 
leading to imperfect elimination of urinary salts. 

2. Direct absorption of one or more of the ingredients of the 
decomposed urine (ammoneemia, urinsemia). 

3. Absorption of purulent or septic matter, produced by decom- 
position of sloughing tissue and organic debris. 

1. Probably in almost all cases of chronic cystitis the kidneys 
are kept in a more or less active or passive hyperiemic state ; and 
while eliminating a normal amount of fluid, fail to rid the blood of 



724: DISEASES OF WOMEN". 

the accumulating salts ; and thereby a slow, steady blood and tissue 
poisoning is brought about. So slow is it, that the system seems to 
establish a certain amount of tolerance for the poison. 

A French experimenter has found that a small amount of urea 
is daily eliminated by the mucous membrane of the bowels in 
health, and we know that in renal diseases, with partial or total sup- 
pression of mine, the bowels are largely concerned in the elimina- 
tion of the poison from the system. In this manner may be ex- 
plained the occasional attacks of vomiting and almost uncontrollable 
diarrhoea in bad cases of cystitis. Of course, when destructive renal 
disease complicates the cystitis, the general j^oisoning is more 
marked and more readily explained. 

2. In the chapter on the function of the bladder I pointed out 
that experimenters had pretty well established the fact that a nor- 
mal vesical mucous membrane was unable to absorb anything except 
possibly a little water, but that where erosion of the epithelial surface 
or ulceration existed, absorption w^as possible. This being the case, 
it will at once be seen how easy it is for a patient suffering with 
chronic cystitis to become poisoned by the absorption of decomposed, 
ammoniacal urine in the bladder. Whether the materies morbi 
be the urea, the ammonia, or all or part of the urine, is not as yet 
definitely settled. This form of poisoning by absorption has been 
denied on the ground that the urine remains but a short time in 
the bladder owing to the intense vesical tenesmus, and that the 
eroded surface is fairly well shielded from contact with the urine by 
mucus or gelatinous pus, and that therefore there is neither time nor 
opportunity for absorption. As against these arguments, let me say 
that of all kinds of urine, the bighly limpid seems the most easily 
absorbed ; that poisoning is not supposed to be due to the fresh 
urine that comes directly from the kidneys, but to its decomposing 
sediment, caught in the meshes of the mucus and muco-pus. Fur- 
ther, the intense vesical tenesmus, while keeping the bladder com- 
paratively empty, thoroughly mixes the decomposing urine with 
the mxucus, thus at each micturition applying freshly charged de- 
composing matter to the eroded and ulcerated surface. It will also 
be observed that in some cases where, by the use of opiates or in the 
course of the disease itself, the tenesmus whoUy or in part abates 
and the urine remains in the bladder for a longer period than usual, 
the patient, while feeling greatly relieved by not having the inces- 
sant calls to urinate, still begins to experience a peculiar sensation 
of sleepiness and the other manifestations of systemic poisoning. 
That this is not due to the opiates or other remedies used, is evident 



OKGANIO DISEASES OF THE BLADDEK. Y25 

from the fact that as large or larger closes of the same remedies do 
not produce these peculiar results wheu given at times when the 
vesical tenesmus is marked. It is undoubtedly explained by the 
fact that the bladder has more time to absorb a part of its contents, 
which, when absorbed, produce these results. 

3. Blood contamination due to the absorption of purulent or sep- 
tic matter. — This material may be the liquor puris, the disinte- 
grated corpuscles of pus, or possibly the whole corpuscles, as also the 
decomposed shreds of sloughed membrane and organic debris. 

I think there is little doubt but that such material is at times al> 
sorbed, and gives rise to the peculiar septicsemic or pysemic symp- 
toms. The chill, fever, and sweating, with peculiar head symptoms 
(all to be spoken of more fully hereafter), the sudden diarrhoea, with 
copious black, offensive liquid stools, are probably caused in this way. 

Whether the general symptoms are produced at the time of each 
absorption, or whether by slow degrees the poisonous material col- 
lects, and, tolerance being finally exhausted, nervous disorder, with 
a powerful effort at excretion by the bowels, results, we do not 
know. 

4. Depraved blood condition — (anaemia). — In cystitis of long 
standing, owing to frequent heeniorrhages, poor digestion, excessive 
diaphoresis and diuresis, and reflex nervous influences, the blood be- 
comes poor in red corpuscles and fibrin. Injuries on persons 
thus affected do not heal readily, and poor tissue renovation is a 
general accompaniment of this affection. Cerebral anaemia is an 
accompanying complication, due to the same cause, and various ab- 
normal nervous phenomena result from poor nourishment of nerve- 
tissue. All the fluids and solids of the body are but poorly con- 
structed, and imperfect performance of function necessarily results. 
This poor blood condition, as I have already said, is manifested by 
the presence of urohoamatin in the urine. 

(^) The Digestive Tract — Anorexia, especially at the morning 
meal, is a common accompaniment of chronic cystitis. In some cases 
this is the only meal w^here the appetite does not invite the patient 
to partake. A longing for peculiar foods is also very common, the 
patient often having lost the desire before the article in question 
reaches her. The common symptoms of disordered digestion are 
usually present, and the affection may be either of the nervous type, 
or of the chronic catarrhal form ; it is usually a mixture of both. 
If, as is believed, the poisonous material absorbed from the bladder 
and the non-eliminated urinary salts find vent through the aliment- 
ary canal, we have no trouble in discovering a cause for the catar« 



726 DISEASES OF WOMEN. 

rhal disorder. The nervous disorders are readily explained by the 
effects of the abnormal condition of the blood, and the broken and 
sleepless nights which interrupt and retard the nutrition of the 
nervous system. 

The bowels are usually irregular and constipated, and require 
daily enemata to open them. This costiveness is occasionally in- 
terrupted by a profuse w^atery diarrhoea, which would seem to be 
an effort of nature to relieve the blood of its abnormal contents, as 
I have already said. It may last for days or for only a few hours, 
and the discharges are usually rich in the carbonate of ammonia. 
The septicemic diarrhoea differs usually in the great prostration ac- 
companying it, the character of the stools (black or greenish black, 
and very offensive, the organic odor quite or partly hiding the 
ammoniacal odor), and the fact that it is usually preceded or accom- 
panied by chills, fever, and sweating. If checked too abruptly, 
head symptoms, mild muttering delirium, etc., are hkely to follow. 

The results of imperfect digestion are seen in the poor, un- 
healthy condition of the patient's flesh and skin, and all the signs of 
malnutrition present. 

(c) The Cutaneous Surface. — The skin of patients with chronic 
cystitis is usually sallow, loose, and has a lifeless feel. Indeed, one 
might almost make a diagnosis from the complexion alone. Sweat- 
ing of the palms of the hands and soles of the feet is common. In 
low states of the system the patients are especially liable to night- 
sweats. The perspiration sometimes has a urinous odor. I have al- 
ready spoken of the septicsemic diaphoresis. 

(d) The JVervous System. — I will first consider the symptoms 
appertaining to the brain and its function, and then to the sub- 
cephalic nervous system. 

There is a peculiar brain condition, supposed by some to be 
caused by cerebral anaemia ; others attribute it to a peculiar poison 
circulating in the blood. By anaemia of the brain in this connec- 
tion is meant not only lack of blood in that organ, but an exceed- 
ingly impoverished condition of the blood there circulating. Those 
remedies that tend to lessen the amount of blood in the brain, as 
bromide of potassium and ergot, produce most unpleasant symp- 
toms in these cases, such as dizziness and fainting. Medicines 
which act in a manner to congest the brain, if given in small doses, 
improve this condition, as also do the ferruginous tonics, especially 
iron by hydrogen. From this it would appear that this peculiar con- 
dition is due more to the amount and imperfect constitution of the 
blood circulating in the brain, than to the absorbed or non-eliminated 



OKGANIO DISEASES OF THE BLADDER. 727 

arinarj matter. Against this theory, however, is the fact that when 
the vesical tenesmus is least and the urine remains in the bladder 
longest, and hence the blood-poisoning is presumably the greatest, 
the weak and somnolent feeling is the worst. Both causes probably 
act to produce this condition. By some, however, this cerebral 
anaemia is attributed partly to the poor blood condition, but chiefly 
to imperfect circulation due to want of exercise. This view is 
supported by the fact that digitalis and exercise in the open air 
greatly improve these patients. 

When septic complications arise and the patient becomes very 
low, or when the septic diarrhoea is checked too suddenly, low, mut- 
tering delirium with hallucinations commonly results. This has 
been alluded to before. The mind is usually markedly affected, 
the patients feeling " blue," morose, lacking hope, confidence, and 
spirit. At times, indeed, they become so despondent as to seriously 
contemplate suicide. The little rest that they get at night is often 
broken by horrible dreams and nightmare. I am now speaking of 
the most severe cases. 

The subcephalic nervous system is seldom affected beyond oc- 
casional irregular action of the heart, chills, fever and sweating, 
and occasional neuralgia. Pains in the nipple, abdomen, arms, legs, 
hands, and feet, are by no means rare. The vesical pain has already 
been referred to. Of course all these symptoms that I have spoken 
of as accompanying cystitis, do not occur in each case, nor are the 
greater part of them peculiar to cystitis alone. I now pass to diag- 
nosis. 

Diagnosis. — The diagnosis of cystitis is generally easy in 
marked cases, but in mild attacks care is necessary to distinguish it 
from other conditions that cause similar symptoms. 

Frequent urination occurs in many other troubles, such as pro- 
lapsus uteri, adhesions from pelvic peritonitis, with abdominal tu- 
mors, and in various neuroses. Pregnancy, also, sometimes gives rise 
to annoying frequency of micturition. Frequent urination from 
prolapsus is worse when the patient is standing or walking, and is 
relieved wholly, or to a great extent, by the recumbent position ; 
while in cystitis, position makes no marked difference. 

I have seen one very interesting exception to this general rule. 
The patient had a complete prolapsus for many years, and when in 
the erect position she could retain the urine for an ordinary length of 
time, but when she was reclining the most urgent desire to urinate 
came on, and she could only retain a very small quantity of urine. 
The cause of this I found to be inflammation of the neck of the 



72S DISEASES OE WOME^. 

bladder. When in the upright position the nrine settled down in 
the dependent poition, but while recnmbent the pressnre came on 
the tender part. 

In adhesions from pelvic peritonitis, abdominal tumors, and 
pregnancT. the desire to nrinate oniv conies on when the bladder is 
partly filled, and is about the same day and night. Frequency of 
urination is not usually accompanied by tenesmus, except when due 
to cystitis. In the various forms of vesical neuroses frequent urina- 
tion is very in-egular, the patient at times being almost entirely free 
from it, and at other times very much troubled. 

The frequent and painful urination of cystitis may be simulated 
by urethritis and other painf id, irritable conditions of the urethra. 
The distinction can be made usually, from the fact that in urethi*al 
disease there is no vesical tenesmus, or if any, it is much less than 
in cystitis. There are acute pain in the act of urination, and a burn- 
ing sensation in the urethra, which sometimes cause sympathetic 
vesical tenesmus ; but when this latter passes off the bladder will 
tolerate distention to the fullest extent. 

The urine should be carefully examined and the results as care- 
fully considered. ImpHcit dependence, however, must not be 
placed on the condition of the mine. Acute or chronic congestion 
may produce consideraljle mucus that is sometimes mistaken for pus 
that has become gelatinous by the action of strong alkali. Pus may 
be present in the urine from suppuration of the upper urinary pas- 
sages (pyonephrosis, renal abscess, and pyelitis) ; fi'om abscesses of 
neighboi-ing organs or tissues opening into the bladder, as in colitis 
and pelvic cellulitis. TThen there is doubt on this point, Sir Henry 
Thompson's method of procedure as recommended by Van Euren 
and Keyes for detecting the source of blood should be tried. 

A differential diagnosis between cvsritis and pyelitis, by means 
of tlie urine alone, is almost an impossibihty, especially in the 
later stages of the former. Thompson's method, the endoscope, 
and the presence or absence of a tiunor in the loins, with the gen- 
eral svmptoms. must be the guides. Xo dependence can be placed 
on the epithelium, as transitional forms from the bladder, as already 
explained, are very likely to be mistaken for the normal epithelium 
of the renal pelves, and lead to error. 

To make a positive and reliable diagnosis, resort must be Jiad to 
physical exploration of the organ. The methods of exploration ai*e 
palpation, percussion, and auscultation of the abdomen ; examination 
of all the pelvic organs by the touch and speculum : and lastly, ex- 
ploration of the bladder by the catheter, or sound. 



ORGAOTC DISEASES OF THE BLADDER. 729 

By palpation and percussion of the abdomen tenderness and dis- 
tention of the bladder may be detected, if either exists. By the 
same means it may be ascertained whether the bladder is contracted 
and its walls thickened, rigid, or relaxed. 

Auscultation will possibly reveal friction sounds in cases where 
inflammation has extended to the serous coat, and caused roughen- 
ing by exudation on the peritoneal surfaces. These may seem to 
be rather delicate points in examination, but in obscure cases we 
must avail ourselves of all the means that can give the slightest evi- 
dence. 

Examination of the pelvic organs by touch will detect any disease 
of these organs that may either cause or complicate the cystitis. 
Displacements and inflammatory affections of the uterus, vagina, or 
rectum, pelvic peritonitis, or the products of a former attack of that 
disease, ovarian diseases and tumors, should be carefully sought for, 
and — if present — their relations to the vesical trouble carefully 
studied. 

Cystitis produced by or producing pelvic cellulitis and peritonitis 
has the same symptoms as ordinary purulent vesical inflammation, 
plus those of well-defined pelvic inflammation. There are usually 
pain and tenderness of the pelvic organs, and the symptomatic fever 
of local inflammation. 

In those cases where, from gluing together of the pelvic organs, 
the bladder-walls are separated and kept upon the stretch, inconti- 
nence often results, sometimes overdistention with dribbling. In 
such cases the cystitis may be entirely secondary to the pelvic ad- 
hesions, and consequent vesical distention. The urethra should be 
examined with care, for some of its diseases present a natural history 
closely resembling that of some vesical affections. 

By a careful use of the catheter or sound introduced into the 
bladder, the degree of tenderness of that organ can be determined, 
and the presence of foreign bodies, such as a stone in the bladder, 
can be excluded. The sound being in the bladder, the finger may 
be introduced into the vagina, and the posterior and inferior walls 
be examined as to their thickness and tenderness. 

In supposed cystitis the neck of the bladder ought always to be 
examined with a view of detecting nlceration and fissures at that 
point. These fissures give rise to symptoms veiy closely simulating 
cystitis, and the differential diagnosis can only be made by the en- 
doscope. 

The endoscope affords the only means of ascertaining the exact 
appearance of the interior of the bladder. The extent of cono-estion, 



730 DISEASES OF WOMEN". 

the degree and extent of ulceration, and other lesions can be observed 
in this way, and this instrument should be used in all cases where 
the diagnosis is doubtful, or w^hen the case does not yelid to supposed 
proper treatment. The chief v^alue of the endoscope is in examining 
the urethra and neck of the bladder. When, by the use of this in- 
strument, urethral disease can be excluded, the diagnosis of cystitis 
may be made by exclusion. If this is not satisfactory, then the 
bladder should be emptied, washed, and thoroughly cleaned of all 
inflammatory products. The catheter should be left to drain off the 
urine as fast as it flows into the bladder. This urine, coming almost 
directly from the kidneys, will show if any renal disease exists. 
Sometimes the bladder is too irritated to permit the presence of 
the catheter ; then the patient should urinate as soon as there are a 
few drachms secreted, and, if there should be any evidence of renal 
disease, the diagnosis would be complete. 

When from an examination of the m-ine or the symptoms it is 
impossible to tell whether disease of the kidneys complicates the 
vesical trouble, recourse may be had to the ophthalmoscope, by means 
of which renal disease, retinitis albuminurica, may often be diagnosti- 
cated. 

Causation. — The cause of acute cystitis may for convenience be 
classed under five heads, each of which will be studied separately : 

1. Direct injuries, such as blows in the vesical region, falls, fract- 
ures of the pelvic bones, violent copulation, sudden uterine displace- 
ments and pressure therefrom, contusions and injuries during labor, 
foreign bodies, rough catheterization, and overdistention from reten- 
tion of urine. 

2. Abnormal urine. 

3. Inflammation of adjacent organs. 

4. Constitutional diseases. 

5. Drugs, improper food, and the virus of gonorrhoea. 

These causes also pertain to chronic cystitis, whether it begins as 
an acute or subacute affection. 

1. Direct Injuries. — Blows over the vesical region, falls, and espe- 
cially fracture of the pelvic bones, caused by some great force, usu- 
ally produce acute inflammation of the bladder, with or without 
rupture of that organ. The bladder, when full, is, of course, more 
readily ruptured than when empty, rupture in the latter condition 
being almost an impossibility. This item of knowledge can be turned 
to practical use in traveling, either by rail or water, by remembering 
to frequently empty the bladder. In cystitis from severe and direct 
injury, even without any perceptible traumatic lesion of the mucous 



ORGANIC DISEASES OF THE BLADDER. 731 

membrane, there is apt to be marked liaemorrhage, nmch greater, 
indeed, than in cystitis from other causes. 

Sudden displacement of other pelvic organs, as the uterus, may 
act in two ways : First, by pressure on the bladder, or by drag£;ing 
it out of place ; second, by blocking the urethra by pressure. These 
displacements may be due to falls or blows, and it is not an uncom- 
mon occurrence for the gravid uterus to topple over by its own 
weight. Supposing a retroversion of the gravid uterus, the cervix 
w^ould compress the urethra against the pubes, while the ntero-vesi- 
eal ligament would drag the upper part of the bladder downward 
and backward. Even after the uterus has been replaced, and the 
pressure on the urethra removed, with relief of the vesical overdis- 
tention, the retention is likely to persist, and overdistention recur, 
for by the pressure the urethra becomes much tumetied, and the 
muscular and elastic tissue of the vesical walls overstretched and 
partly paralyzed. If the distention has been great and prolonged, 
there may be partial or total sloughing of the vesical mucous mem- 
brane. 

In retention of urine, and consequent overdistention of the blad- 
der during or after labor, from either injury or carelessness, acute 
cjstitis is very apt to occur. Here injury of a serious nature may 
be done to the urethra by pressure against the pubic bones by the 
child's head, with or without the intervening soft cushion of the 
anterior uterine lip. This is especially the case in slow, tedious 
labors, where the pressure is almost continuous. 

The extent to which the bladder may be distended without rupt- 
uring is quite wonderful. My friend Dr. Bodkin invited me to see 
a lady with him in consultation, who went without urination for four 
days and nights after her confinement. The bladder reached above 
the umbilicus, and contained about three ox&msiVj pots-de-chambre 
full of decomposed urine, which was drawn off by the catheter. The 
bladder remained paralyzed for three months afterward, but finally 
regained its expelling power. At the time I saw her she was suf- 
fering from cystitis, brought on by the maltreatment. In justice to 
the medical profession, I ought to say that this lady was attended 
in her confinement and for a time after by a member of the so-called 
new school of medicine. 

The ignorant or careless use of instruments during delivery is 
also a cause of serious vesical inflammation. In all these cases the 
catheter should be used several times daily, and with great care, 
until the organ has regained its power, and the contused urethra 
fully recovered itself. I may digress here long enough to say that 
48 



732 DISEASES OF WOME!^. 

the soft-rubber catheter is the only one that I have used for years. 
The old female silver catheter is the most dangerous instrument I 
have ever seen. It shonld be discarded forever. In cases where 
the bladder has been perfectly healthy, and the catheter passed a 
number of times by way of experiment, the points of membrane 
with which the instrument had come in contact were abraded and 
congested, thus showing the danger attending the unskillful nse of 
this instrument. If the frequent introduction of the instrument into 
a healthy bladder produces these results, how easily must the blad- 
der of a pregnant woman be inflamed under such treatment, for the 
organ has been for a time more or less congested, and during labor 
perhaps severely bruised ! 

The question has been raised as to whether the irritation and in- 
flammation following catheterization in some cases is not due to the 
introduction (during manipulation) of air, either pure or containing 
germs that will cause decomposition of the urine. The experiments 
of P. Dubelt, in which the air was injected into the bladder, show 
that it is perfectly harmless. Moreover, the same experimenter 
found that the injection of decomposing urine into the bladder did 
little or no harm, unless the mucous surface was abraded. What- 
ever may be the effect of such things on a healthy bladder, I do not 
doubt but that the introduction of germs by means of air or a dirty 
catheter, decomposing urine, or the rough or too frequent use of a 
catheter, would produce an acute exacerbation in an organ already 
diseased. 

The influence of decomposed or decomposing urine in producing 
inflammation of the bladder will be more fully spoken of again. 

Forcible and excessive copulation is a decided exciting, as well 
as predisposing, cause of acute or subacute cystitis, and, if persisted 
in, a chronic inflammation of the bladder is usually the result. 

Foreign bodies in the bladder, such as pieces of wood, pins, 
needles, hair-pins, bodkins, and the like, that are sometimes slipped 
in by hysterical girls and those who masturbate, excite acute inflam- 
mation if not speedily removed. 

2. Abnormal Urine. — 'No known abnormality of the urine will, I 
think, excite acute inflammation in a perfectly healthy bladder. In 
a bladder, however, that is suffering from chronic congestion; in 
one whose walls bear deposits of tubercle ; in cases where some 
slight degree of inflammation already exists, then abnormal urine 
may and does give rise to marked inflammatory trouble. As a rule, 
however, inflammatory vesical disease precedes urine decomposition. 
In cystitis following overdistention, the retained urine, being mixed 



ORGANIC DISEASES OF THE BLADDER. 733 

with mucus thrown out by the irritated and tense mucous membrane 
to shield itself, rapidly decomposes, and still further aggravates the 
abnormal condition of the membrane. 

Women sometimes from abnormal modesty, more often from 
the lack of opportunity, retain their urine until the bladder is dis- 
tressingly overdistended, and the urine partially decomposed. Of 
course this is wrong, and can generally be avoided, but is neverthe- 
less a frequent cause of disease of this organ. 

Where there is considerable suppuration of the upper urinary 
passages (renal abscess, pyelitis, or pyonephrosis), the acid urine 
loaded with pus has, or seems to have, an irritating effect on the 
vesical mucous membrane, and in some instances probably lights up 
a cystitis, and certainly aggravates one when already existing. 

Deposits of the amorphous phosphate of Hme, or of the ammonio- 
magnesian phosphate, often greatly aggravate and render serious a 
previously mild cystitis, but seldom if ever produce acute inflamma- 
tion in a healthy bladder. This may be said also of uric-acid gravel 
and other crystalline urinary sediments, they being at most only able 
to produce some hypersemia of the membrane with a little excess of 
the mucous secretion. 

Urine which is already decomposed, or decomposing, as I have 
already said, can produce acute cystitis only in an already diseased 
bladder, or in one where abrasions of the epithelial surface exist. 

To show how some of these causes may combine to produce cys- 
titis, let me take, for example, the bladder of a pregnant woman, 
which has for some time shared congestion with the other pelvic 
organs. Retention and some distention of the bladder occur from 
some cause ; a clumsy physician attempts to pass a metallic catheter, 
and does it roughly and rapidly, and relieves the viscus of its con- 
tents. A slight catarrh of the mucous membrane, the surface of 
which is somewhat abraded, ensues. By the catalytic action of the 
mucus present in it, the urine is rapidly decomposed. The decom- 
position is often aided by germs introduced with the catheter. Car- 
bonate of ammonia, being set free from the broken-down urea, as- 
sists in alkalizing the fluid, precipitating the amorphous phosphates 
thereby, and forming, with the phosphate of magnesia already pres- 
ent, the ammonio-magnesian, or triple phosphate. The urine is 
further alkalized by the alkali of the mucus. The bladder-walls not 
having fully regained their tone, a little decomposed urine remains 
after each micturition, and aids in decomposing that which is next 
secreted, and would otherwise be normal. The mucus increases in 
amount, the ammonia is more rapidly set free, and the mucous 



734 DISEASES OF WOMEN. 

membrane more and more irritated, until a true acute cystitis is set 
up. Such cases are of almost daily occurrence. 

The decomposed urine alone, however, produced without the 
overdistention or without the abrasion would not have occasioned a 
true acute cystitis, but might possibly by slow gradations have worked 
up a subacute cystitis. The rule, if it may be called such, is the 
one that I have already given — viz., that some abnormality of the 
urinary organs (as catarrh) almost invariably precedes urinary de- 
composition. 

3. Iiiflammatioii of Adjacent Organs. — Acute cystitis may arise 
from the extension of inflammation from neighboring organs, as in 
vaginitis, metritis, uterine and vaginal cancer, extra-uterine pregnancy, 
abscesses of the colon or other organs opening into the bladder, pelvic 
peritonitis, cellulitis, etc. Gonorrhoeal inflammation of the urethra 
may extend to the bladder. As gonorrhoea of the female urethra is 
comparatively rare, such an extension is seldom seen. When it 
does invade the urethra, it is very apt also to extend to the bladder, 
and is very severe. Inflammation of the renal pelves and ureters 
may extend to this organ, and cause cystitis, the usual course, how- 
ever, being from the bladder to the ureters and the kidneys. 

4. Certain diseases of the general system affect the bladder, 
such as the eruptive fevers. In scarlet fever, and measles especially, 
I have noticed that the mucous membrane of the bladder suffers, to 
some extent, like the mucous and tegumentary tissues elsewhere. 
Diseases of the heart and liver act more as predisposing causes, by 
producing chronic vesical congestion, than as exciting causes, and 
when they do produce cystitis it is usually of a low chronic type. 
Old age, when the has fond is greatly deepened, acts more as a pre- 
disposing cause, by allowing the collection and decomposition of 
urine. Paraplegia and other affections of like nature, by allowing 
overdistention and decomposition, as a rule, produce cystitis, but of 
a low form. 

5. Drugs, Improper Foods, and the Virus of Gonorrhoea. — Of all 
drugs, cantharides is undoubtedly the most active in producing true 
acute cystitis. In many cases it produces simple irritation and hy- 
persemia, stopping short of actual inflammation. Arsenic and tur- 
pentine also produce irritation and active hyperaemia, but seldom if 
ever go further. 

Alcoholic beverages persisted in for a length of time act more as 
predisposing than as exciting causes. They may, hoTf-ever, produce 
a low grade of cystitis, or, like the medicines givem above, light up 
an acute process in an already diseased vesical membrane. Dr. A. 



OEGANIC DISEASES OF THE BLADDER. 735 

Jacobi lias seen aggravated cases of cystitis caused bj the free and 
long-continued use of large doses of the chlorate of potassa. 

The various foods can not produce acute cystitis in a healthy 
bladder, but may aggravate an already diseased condition. The 
prohibition, therefore, of stimulating condiments, alcohol, asparagus, 
and onions, in these diseases will at once suggest itself. I have al- 
ready spoken of gonorrhoea as a cause of cystitis, and need not dwell 
on it here. 

M. Eugene Monod (" Annales de Gynecol.," May, 1880), in dis- 
cussing the question of cystitis, presents the following conclusions : 

1. The urinary symptoms incident to pregnancy proceed from 
two different causes, to each of which there corresponds a distinct 
clinical group of symptoms. The first group receives its ex- 
planation from the pressure produced by the gravid uterus, which 
leads to retention of urine. The second is caused by vesical con- 
gestion which results from the predisposition of the bladder to in- 
flammation, owing to its close vascular connection with the uterus. 

2. During the first weeks of utero-gestation, there may occur a 
variety of acute cystitis which is unquestionably caused by the de- 
velopment of pregnancy. 

3. Immediately after, or during the first weeks following nor- 
mal delivery, there may arise a variety of cystitis which, owing to 
the time of its appearance, deserves to be called post-puerperal cys- 
titis. 

4. The anatomical relations between uterus and bladder, as Avell 
as their vascular interconnections, account for the frequency of ves- 
ical disorders accompanying many uterine maladies. Certain phys- 
iological changes of the bladder during menstruation, and at the 
time of the menopause, also influence the establishment of bladder 
troubles. Thus there is seen to exist a whole class of vesical in- 
flammations belonging only to women, and, contrary to the gener- 
ally accepted opinion, cystitis is by no means rare in women. 



CHAPTEE XLI. 

ORGANIC DISEASES OF THE BLADDEE (cONTINUED). 

TREATMENT OF CYSTITIS — CROUPOUS AND DIPHTHERITIC 
CYSTITIS— CYSTITIS WITH EPIDERMOID CONCRETIONS. 

Cystitis requires both local and constitutional treatment, and 
withal it is a troublesome disease to manage, especially in its chronic 
form. The constitutional treatment consists, first of all, in so regu- 
lating the character of the urine that it shall be unirritating to the 
diseased organ. Pain and vesical tenesmus should be relieved if 
possible. The skin should be kept in a healthy and active condi- 
tion and the bowels regular and free, in order to prevent all strain- 
ing at stool and secure free action of the portal circulation. Free 
elimination by the skin and bowels will give the kidneys and blad- 
der less to do. To overcome existing constipation, saline laxatives 
should be used. A glass of purgative mineral water, given an hour 
before breakfast, answers very well in most cases. Cold-water ene- 
mata are advised by good authorities. 

Winckel recommends the use of saline laxatives, pushed to a 
point where intestinal hyperasmia is produced and maintained for a 
time. He believes that the blood may, in this manner, be to a cer- 
tain extent diverted from the bladder ; and I am of the belief that 
the practice is a sound one. A case of my own is of interest as 
showing the benefit effected (supposably) in this way. A lady had 
catarrh of the bladder of some months' standing, which I had been 
treating in the usual way, with only slight benefit. She was one 
day attacked with cholera morbus with serous purging and vomiting, 
the former almost as severe as that of Asiatic cholera. The effect, 
for a time was to almost suspend the action of the kidneys. When 
she recovered, she was delighted to find that her cystitis had left her. 

Among the conditions which produce irritating urine, and hence 
tend to produce cystitis or to aggravate it if it already exists, are 
malnutrition from any cause and the strumous, gouty, and rheu- 
matic diatheses. When either of these is present it should be 



ORGAMC DISEASES OF THE BLADDER. 737 

treated for the general good of the patient and the indirect effect 
upon the bladder. 

The diet of patients suffering from this disease must be care- 
fully regulated. Milk will be found to agree excellently in most 
cases. In the hands of Dr. George Johnson, of England, an exclu- 
sive milk diet has cured several cases, some of great severity and 
long standing. 

He says : " The milk may be taken cold or tepid and not more 
than a pint at a time, lest a large mass of curd, difficult of digestion, 
form and collect in the stomach. Some adults will take as much as 
a gallon in the twenty-four hours. With some persons the milk is 
found to agree better after it has been boiled, and then taken either 
cold or tepid. If the milk be rich in cream, and if the cream disa- 
gree, causing heartburn, headache, diarrhoea, or the symptoms of 
dyspepsia, the cream may be partially removed by skimming. 
Constipation, which is one of the most frequen-t and troublesome re- 
sults of an exclusively milk diet, is to some extent obviated by the 
cream in the unskimmed milk. When the vesical irritation and ca- 
tarrh have passed away, solid food may be combined with the milk, 
and a gradual return made to the ordinary diet." 

I have tried this method of treatment in several instances with 
decided benefit. 

I may briefly state that the bill of fare usually given consists 
largely of fluid foods, as milk, yolk of egg. soups, and beef essence. 
Lean meat in small amount, and other solid or semi-solid foods that 
are easily digested and nutritious, may also be allowed. The cause, 
whatever it may be, should be removed, if possible ; and the reme- 
dies must be adapted to the stage and condition of the inflammation. 
In the acute stage aggravated by exposure to cold, diaphoretics 
should be freely used, and the patient made to rest as quietly as pos- 
sible. Diuretics should be given if the urine is loaded with solid 
material, and the alkaline salts are to be preferred. Yichy water 
or flaxseed tea with citrate or nitrate of potash, will answer very 
well at the beginning of the treatment. In using such salines, it 
cerves admirably to give them in an infusion of buchu in case the 
patient's stomach does not rebel at the taste of it. This of itself is 
a most valuable remedy in almost all bladder affections. Care must 
be taken, however, not to push diuretics too far. Sufficient to bring 
the urine to its normal proportions, and make it slightly alkaline if 
naturally acid, is all that is required. 

In the early stages of acute cystitis, as well as in irritable blad- 
der, Sidney Ringer and other authorities strongly commend the use 



738 DISEASES OF WOMEX. 

of minim doses of tincture of cantliarides repeated every horn*, and 
even oftener, but I have not seen very good effects from its use in 
cystitis. 

One or two leeches to the anterior vaginal wall may be tried, 
and hot applications to the epigastrium in acute cases. To relieve 
pain, opium is indicated. Dover's powder is very valuable, and 
may be given with ordinary doses of camphor. If there is any ob- 
jection to anodynes given in this way, or if there is sympathetic 
rectal tenesmus, suppositories of morphia and belladonna should be 
used. 

AVhile I have said that opium may be used at the onset of acute 
cases, and to relieve the saffering in old cases that can not be cured, 
I must impress upon the mind the great hann that may come from 
the injudicious use of this drug in cystitis. It deranges the digestive 
organs and the secretions generally, especially that of the kidneys ; 
and, by changing the quantitative composition of the urine, renders 
it irritating to the bladder. 

In some cases, where frequent urination and tenesmus are very 
severe, owing to excessive nervous irritability, twenty-grain doses of 
the bromide of potassium, every four hours until relieved, act very 
nicely ; indeed, this succeeds in cases where opiates fail entirely. 
Recently I have used hydrobromic acid and iind that it acts even 
better than the bromide of potassium in some cases. 

The comparatively new drug, eucalyptus globulus, is worthy of 
a trial in obstinate cases. From its well-marked beneficial action in 
albuminm'ia and other affections of the urinary tract. Dr. AY. Ander- 
son was led to try it in cystitis, and he reports it as decidedly useful. 
Dr. J. J. Mulheron, of Detroit, gives it in doses of twenty minims in 
subacute cystitis with good results. As this remedy has tonic, 
antiperiodic, and antiseptic properties, it might be especially suit- 
able in malarious districts. An infusion for injection in cases where 
the mine was decomposed, would most probably give good results. 

Benzoic acid is perhaps the drug that would be found most use- 
ful in the largest number of cases. It often seems to act like a spe- 
cific, giving speedy and permanent relief. It may be given in about 
ten-grain doses, in infusion of buchu, thi-ee or four times a day. As 
the acid is sparingly soluble in cold water, an equal proportion of 
borax may be added to the mixture. To insure a perfect solution, 
one may prescribe the benzoate of ammonia, which in the same dose 
acts admirably, and is more palatable. 

In the more advanced stages of the disease remedies are used for 
their direct effect upon the mucous membrane, and much good is 



ORGANIC DISEASES OF THE BLADDER. 739 

obtained in this way. The drugs which have the best reputation in 
urethritis are employed in cystitis. Balsam of Peru and of copaiba, 
oil of turpentine, and tar-water are the- most important of this class, 
and should be given in capsules in the same way as for gonorrhoea. 
Oil of sandal-wood is also valuable in chronic cases. 

When the pain is not severe, and the urine is loaded with mucus 
and pus, astringents should be given. Tannin continued for a con- 
siderable time is of very great value. Decoction of uva ursi, in 
half-ounce doses, may also be used for this purpose. In place of 
these, I have employed, with occasional good effect, a mixture com- 
posed of two ounces fluid extract of buchu, one ounce tincture of 
conium, and one grain and a half sulphate of morphia, giving tea- 
spoonful doses every three or four hours. When pain is not severe, 
the morphine should be omitted. 

Dr. E. A. Segur, of this city, has used salicylate of soda in puru- 
lent cystitis, and found that the quantity of pus in the urine rapidly 
decreased under the use of this remedy. 

Dr. Sansom, of London, found that the administration of carbolic 
acid and the sulpho-carbolates to animals prevented the decomposi- 
tion of urine, although lie could not detect any of the salt in the 
secretion. He gave the sulpho-carbolates, and afterward collected 
and preserved the urine, which after six months had not decomposed. 
This fact should be kept in mind, and turned to account in cases 
where there is a tendency to decomposition from retention or otlier 
causes. 

An English physician reports, in the " Canadian Practitioner," 
that he has met with no case of offensive urine (intestinal -vesical 
fistula excepted) that ten or twenty grains of boracic acid given every 
three hours would not cure. All these remedies may be tried in 
cases that are seen early ; but, when they fail, or when the acute 
stage of the trouble is long past before advice is sought, then local 
treatment must be employed. The bladder should be washed out, 
and medicated injections used. This every surgeon will feel com- 
petent to do, no doubt, but I must give some general directions as 
.to the methods of manipulating, as I feel assured that much of the 
good which ought to come from this kind of treatment is lost, and 
harm done instead, by not clearly knowing how to perform this op- 
eration, which I consider both difficult and very important. 

There are certain rules which ought to be carefully observed in 
washing out the bladder. The catheter should be suflficiently soft 
and flexible to be incapable of injuring the bladder or urethra ; it 
should be surgically clean ; the bladder should be emptied slowly, 



740 DISEASES OF WOMEl!^. 

especially when withdrawing the last of its contents, otherwise the 
bladder will contract abruptly upon the catheter, and be injured 
thereby ; instillations should be made very slowly (the bladder can 
not be rapidly distended without injury), and the quantity used 
should not be more than the patient can tolerate without pain. An 
ounce is sufficient, and much less will suffice if more gives pain. 
When the quantity which can be borne is determined, the instillation 
and withdrawal of that quantity can be repeated until the desired 
eSect is obtained. 

By carefully following these rules, the possible benefit of local 
treatment can be obtained. Neglect of these will certainly bring 
disfavor npon the method. Some years ago I employed a rather 
complicated arrangement for washing out the bladder, consisting of 
a reflux catheter with a fountain attachment. It was the best that 
I could find at that time, but I have long ago discarded it for a sim- 
pler and much better instrament. I use now a soft-rubber catheter, 
having attached to it a piece of rubber tubing, these being joined 
by a piece of glass tubing, the whole being about two feet in length. 

A small glass funnel is 
introduced into the end 
of the rubber tube, and 
this completes the instru- 
ment (Fig. 229). 

This is used as a cathe- 
ter to empty the bladder 
of urine, and then, leav- 
ing it still in place, the 
washing out is accom- 
plished by pouring the so- 
lution to be used into the 
funnel, and raising it high 
enough to make it flow into the bladder. The funnel is then lowered 
to permit the fluid to escape, and the process is repeated as often as 
may be necessary. Any desired quantity of fluid can be instilled into 
the bladder at any degree of pressure that may be necessary for the 
comfort of the patient, and the fluid can be drawn off slowly or rap- 
idly by elevating or depressing the funnel. It is very important not 
to let air enter the bladder, and this can be accomplished by letting 
the patient retain a few drachms of urine before beginning the 
treatment. When the catheter is introduced, and the urine in the 
bladder drawn off", enough of the urine will remain in the catheter to 
fill it, and, by filling the funnel before elevating, the fluid used will 




Fig. 229. — Fountain-syringe for washing bladder. 



OKGANIC DISEASES OF THE BLADDER. 741 

meet the urine in the catheter and exclude the air. In case the blad- 
der is emptj, the catheter should be tilled before introducing it into 
the urethra, and the air will be excluded in that way. When once 
the process of washing is begun, the exclusion of air is easily man- 
aged by regulating the elevations and deipressions of the funnel, so 
that the catheter and tube will be kept full all the time. 

This instrument fulfills all the indications perfectly, and very 
little practice is necessary to enable one to use it with facility. When 
the bladder has been thoroughly cleansed in this way of all inflam- 
matory products, medicated applications may be made in the same 
manner. The quantity of fluid instilled, the length of time it is left 
in the bladder, and the time occupied in making the instillation and 
withdrawing it can all be regulated according to the will of the sur- 
geon and the toleration of the patient. 

Much care should be taken in lubricating the catheter so that it 
can be introduced readily. Oil has been used for this purpose, 
and I believe that some surgeons use it still. Castile soap and water 
or vaseline answers much better. The oil decomposes, and renders 
the catheter unclean unless great care is taken to wash and disinfect 
the instrument very thoroughly. In fact, it is hardly possible to 
keep a catheter clean for any length of time if oil is used as a lubri- 
cant. Yaseline is best, and, if that is not at hand, then soap will an- 
swer. Cleansing the catheter after use requires more than a passing 
notice. I have found that if a soft-rubber catheter is simply washed 
after use in the ordinary way — i. e., by washing it off with warm 
water, and then rinsing it in a mild solution of carbolic acid — say 
five per cent — it becomes very foul. A catheter used in that way 
for a few days will be found swarming with bacteria on the inside. 
Such an instrument is dangerous, and should never be used. In my 
private hospital each patient has a catheter for herself alone, and, 
when she is through with it, it is destroyed. After each time that a 
catheter is used it is well washed in hot water, and then kept in a 
ten-per-cent solution of carbolic acid, and once in every twenty-four 
hours it is kept for fifteen or twenty minutes in boiling water. With 
all this care the catheter can be kept clean and safe for use. 

Simply washing out the bladder is often beneficial, and ought to 
be repeated frequently. It should always be done before using any 
medicated application. Warm water alone is usually employed, but 
the addition of chlorate of potash or common salt makes it less irri- 
tating to the bladder. I prefer borax or common table-salt, using 
about sixty grains to the pint of water. It is generally conceded 
that salt and water are more acceptable to serous and mucous mem- 



742 DISEASES OF WOMEN. 

branes than any other fluid, because more like the normal secretion 
of these parts ; but I have not found it any better, if as good, as 
borax. When there is ulceration or suppuration, carbolic acid and 
water make a most valuable wash. A drop to the drachm or there- 
about is the proper propoiiion. 

Having prepared the bladder for local applications by carefully 
washing it out, the material to be used may be selected from a long 
list of remedies. I shall mention only a few — those which I believe 
to be the most valuable. I need hardly say that anodynes have been 
tried most faithfully. The painful character of the disease suggests 
their use, but they are neither reliable nor very eifectual. The 
mucous membrane of the bladder is not intended to absorb, and, 
therefore, very little of the anodyne effect of opium, or any of its 
preparations, is obtained when injected, even when the dose is very 
large. Should there be ulceration, then the local and constitutional 
effects of morphia will be produced by absorption. Braxton Hicks 
uses one or two grains of morphia to the ounce of water as an in- 
jection, allowing the patient to retain it as long as possible, and 
claims good results from its use. Remedies which produce local 
anaesthesia do relieve the pain to some extent, but not altogether, 
by any anodyne action, such as we get from opium given by the 
mouth or rectum. Cocaine relieves the pain for a short time, but 
not long. Its chief value is to benumb the parts so that curative 
applications may be more easily made. In some cases it acts as 
an irritant. Chloral hydrate is recommended to relieve the pain. I 
have nsed it in solution, ten to fifteen grains to an ounce of water, 
and found benefit from it. 

The astringent and alterative injections most beneficial and most 
commonly used are nitrate of silver, sulphate of zinc, tannic acid, 
and acetate of lead. My rule is to use one or two grains of either 
to the ounce of warm water, and to increase the quantity if no good 
effect comes from the small doses, but to carefully avoid injections 
strong enough to cause much pain. Chlorate of potash is valuable, 
and perchloride of iron is said to be useful. Infusion of hydrastis 
Canadensis has been used, and great virtue is claimed for it. I have 
tried it, and believe that it acts well in some cases, but still it fails, 
like the rest, in others. When the urine is alkaline and offensive 
from long retention, which is occasionally the case in prolapsus of 
the bladder, then nitro-hydrochloric acid, of the strength of two 
minims to the ounce of water, should be used. "Whenever pain is 
caused by any of these astringent injections, morphia should be used 
afterward, as directed by Braxton Hicte. 




ORGANIC DISEASES OF THE BLADDER. 743 

In obstinate cases a strong solution of nitrate of silver is one of 
the most reliable remedies. Twenty grains to the ounce of water 
has been used with great benefit, and it does not cause as much pain 
as might be supposed. Yerj small quantities only can be used at 
a time — not more than Hve or ten drops. The only trouble which 
I have experienced is in being sure of injecting that small quantity 
and no more. My favorite method of making such applications to 
the interior of the bladder is by instillation, as it is called. I take a 
glass tube of the size and shape of a 'No. 8 or 9 male sound, with a 
small rubber bulb attached to the straight end. The curved point 
is introduced into the solution to be used, the bulb is compressed by 
the thumb and finger, and then relaxed, which draws up the desired 
amount. The tube 
is then carried into 
the bladder, and, by 

. Fig. 230.— Skene's instillation tube. 

agam compressmg 

the bulb, the fluid is easily deposited in the organ (Fig. 230). 

If a larger quantity is to be used, it can be introduced through 
the instrument used for washing out the bladder. In fact, I seldom 
use the pipette now except for medicating the urethra. 

There is one rule that should be followed in using nitrate of sil- 
ver in the treatment of cystitis, which is this : If a strong solution 
is used, only a few drops should be employed, and, if a large injec- 
tion is made, the solution should be mild. I am indebted to Prof. 
John W. S. Gouley for this valuable guide in the use of this remedy. 

J^ormal urine has been highly recommended as an injection in 
cystitis. The urine from a healthy person is obtained and used in 
the same way as the other injections described. I have always looked 
upon this treatment with a little suspicion. It may be of value in 
cases where from some derangement of the general system the urine 
secreted is abnormal, and therefore irritating to the bladder, and 
where constitutional treatment can not remove that condition. When 
the urine secreted can be kept in a normal state, it must, it seems t© 
me, be as acceptable to the bladder as the same kind of urine from 
another person. Theoretically, one would expect that healthy urine 
poured into the bladder from the kidneys would be more likely to 
cure cystitis than if it were injected through the urethra. However, 
this method may be of value; but one thing is certain — it fails like 
all other injections in certain cases. 

Iodoform has been used locally in cystitis, and Avith good effect ; 
but I regret to say that I have not used it enough to test its merits 
fully. 



744 DISEASES OF WOMEN. 

One great obstacle often met with in using instillations is a ten- 
der or inflamed urethra. This difiicultj I have recently been able 
to overcome by using cocaine. It is applied as follows : I take a 
pipette like the one described above but larger, fill it with cocaine 
solution, and introducing the tapering part of it into the meatus, force 
the solution along the urethra and into the bladder. This often 
makes the rest of the treatment easy. 

Another direct method of treating the bladder has been employed 
by Dr. Robert Newman, of New York, who has made some useful 
contributions to the therapeutics of vesical disease. He employs 
the endoscope of Desormeaux to make the diagnosis, and makes 
direct applications to the diseased parts through that instrument. In 
ulceration, he has been very successful in his practice. He applies 
a solution of the nitrate of silver (twenty grains to the drachm of 
water) to the ulcerated surface, and by carefully regulating the 
amount, finds that the pain is less than when a weaker solution is 
used in the ordinary way. I have done the same thing with greater 
facility by using the endoscope which I have described. The in- 
strument is introduced, and the ulcerated part found ; the glass tube 
is drawn out, and the application made directly to the diseased part, 
through the rubber speculum. Forcible and extreme dilatation of 
the urethra has been advocated in the treatment of cystitis by many 
surgeons otherwise well informed. Within the past few years the 
medical journals have contained the histories of many cases of cys- 
titis said to have been cured by this operation. This is all quite er- 
roneous. Cystitis can no more be cured by dilating the urethra 
than could a gastritis be cured by dilating the sphincter ani. It is 
a fact that if the urethra be destroyed by overdistention, inconti- 
nence will follow, and the perfect drainage of the bladder may 
cure the inflammation ; but verily the cure is worse than the 
disease. I am sure that the mistake in regard to the value of this 
operation in cystitis comes from its having been practiced in cases of 
acute cystitis which would have ended in recovery without any sur- 
gical treatment, and again in cases of inflammation of the upper 
third of the urethra which have been mistaken for cystitis. On the 
one hand the operation gets the credit of curing a disease which 
cured itself, and on the other of curing a disease which did not ex- 
ist. It will be observed that in the cases which I give at the close 
of this section, the urethra was dilated with no benefit, and to these 
I could add many others which were treated in the same way with a 
like result. 

All the means of treatment yet described will fail in some of the 



ORGANIC DISEASES OF THE BLADDER. 745 

worst cases of chronic cystitis. Indeed, this has led to the last re- 
sort, as I look npon it, namely, cystotomy for the establishment of 
vesico-vaginal fistula to drain the bladder and set it at rest. The 
perfect rest obtained by the urine flowing out through the fistula as 
soon as it enters from the ureters places the inflamed surfaces in a 
condition to recover, and the patient is relieved from the constant 
pain and the torments of urinating every few minutes night and 
day. 

This is certainly a great triumph, and is especially applicable in 
cases that are incurable by all other means. Indeed, it is adapted to 
cases which are incurable by this operation, because it gives relief 
from pain, and makes the last days of an incurable sufferer tolerable. 
Dr. Willard Parker, I believe, was the first to do cystotomy for 
the cure of cystitis in the male, and Dr. T. A. Emmet adopted the 
operation, and has practiced it extensively among his female patients. 
In fact, he has become a zealous advocate of this method of treating 
cystitis. In his book on gynecology, in speaking of cystitis in 
women, he says that our management of this aft'ection is limited to 
one procedure, and that is vaginal cystotomy. 

Such a dogmatical statement is quite in opposition to facts well 
known to many in the profession. Drainage by vesico- vaginal fist- 
ula is neither the surest, safest, nor simplest method of treating cys- 
titis in women, but only one method to be employed in those rare 
cases which do not yield readily to other means. 

While writing on this subject some years ago, I obtained from 
one of the resident surgeons of the Woman's Hospital the statement 
that cystotomy was performed for the relief of cystitis on seventeen 
cases in that institution, and that four were cured and thirteen im- 
proved. This shows about twenty-four per cent of recoveries, and 
this I stated in my book on " Diseases of the Bladder." Dr. Em- 
met in his book on gynecology objects to this statement of mine as 
not being in accordance with a published report of the Woman's 
Hospital. The report referred to was not published at the time that 
I prepared my manuscript, nor did I see it until after my book was 
published. I presumed that the interne of the hospital gave me a 
correct report, but be that as it may, Dr. Emmet's own statistics (as 
given in his book, page 788) of the hospital practice are less favor- 
able to cystotomy for the cure of cystitis than those quoted by me. 
They show but about twenty per cent of recoveries, whej'eas my 
statement obtained from the interne was twenty-four per cent. This 
shows that if I made a mistake it was in favor of the operation ; or 
else if I was correctly informed of the results of that operation at 



746 DISEASES OF WOMEN. 

that time J then the subsequent hospital experience of Dr. Emmet 
has been more unsatisfactory. Dr. Emmet's method of making 
the fistulous opening is bj dividing the vesico-vaginal septum 
with the scissors, and then introducing a glass tube to keep the 
opening from closing. This is the most difficult way of operating 
and the most painful to the patient afterward. The wearing of 
this tube has been a torture to those that I have seen using it. 
There are two other methods of operating. Oue is to make the 
opening, and then stitch the mucous membrane of the bladder to 
the raucous membrane of the vagina, thus preventing the closing 
of the opening, and at the same time enabhng the edges of the 
wound to heal in a short time, a great gain in itself. The other 
method is to make the opening with the galvano- or thermo-cau- 
terv. Dr. M. A. Fallen was the first to operate with the thermo- 
cautery. This is what he says about it : " The main difficulty 
hitherto has been to keep the incision open after the use of the 
scissors or knife. Artificial means must be resorted to, such as an 
India-rubber tube passed from the urethra through the opening, 
which is annoying and painful ; or a glass button introduced, 
which is difficult to retain, and when retained is apt to beget vesical 
tenesmus. I believe that the use of the actual cautery at a red 
heat will be found to answer all purposes. If the platinum tip 
is at a white heat it cuts through too rapidly, and we are apt to have 
as much haemorrhage as with the knife or scissors. Haemorrhage is 
sometimes quite serious after incision of the vesico-vaginal septum, 
particularly if the scissors or knife strike the tortuous, enlarged 
veins, often ramifying upon or under the mucous membrane of 
the bladder. If the platinum tip of the cautery be heated to a 
white heat, it cuts through as rapidly as the knife, and therefore the 
haemorrhage is to be expected ; besides, the thin pellicle of slough 
following the white-heat tip soon peels oH, and union might ensue. 
To avoid both bleeding and contraction, the red-heat tip should be 
slowly passed along the site of the proposed opening, dividing first 
the mucous membrane of the vagina, and then resting for a moment 
or so to allow the adjacent vessels to contract and become throm- 
botic. The submucous connective tissue is then burned, and after- 
ward the bladder-wall itself. Extreme delicacy of manipulation is 
required upon the part of the surgeon, lest he burn directly into 
the cavity of the bladder, which should be avoided if he wants to 
make sure of a result that will prevent haemorrhage, contraction, 
and subsequent union. 

'• The care after an operation of this kind consists in daily cleans- 



ORGANIC DISEASES OF THE BLADDER. 747 

ing the bladder tlioroiiglilj with demulcent warm fluids, such as 
starch or flaxseed water. The pain in the bladder following the 
burning is comparatively slight, aud usually subsides within thirty-six 
or forty-eight hours." 

Dr. John Byrne, of Brooklyn, operates in a very easy and satis- 
factory manner. He has a forceps, one blade of which is intro- 
duced into the bladder and the other into the vagina to grasp the 
vesico-vaginal septum. The blade in the vagina is fenestrated and 
the blade in the bladder is grooved. The thermo-caatery knife is 
introduced through the fenestrum of the forceps and the septum is 
divided, the knife being guided by the forceps. 

This method makes the operation simple and easy, and the after 
Treatment is also greatly simplified. 

One serious drawback to cystotomy is the incontinence which 
keeps the patient in such an uncomfortable state by the constant 
trickling of urine from the fistula. I tried to obviate this trouble 
to some extent by using a hollow-globe pessary, made of hard rub- 
ber, with a tube attached to it. The globe is perforated with nu- 
merous small holes all around, except for about half an inch from 
where the tube begins. The globe is introduced into the vagina, 
and the tube projects through the introitus. The urine collects in 
the globe, and escapes through the tube ; and by attaching a piece 
of flexible tubing to it the urine can be conveyed into a vessel. 
When the introitus vulvae is small and the sphincter vaginae perfect, 
this answers very well, especially during the night, when the patient 
is in the horizontal position. When worn during the day, it is ne- 
cessary to have a rubber bag attached to the leg of the patient to act 
as a receptacle. 

Encouraged by my success with the globe-pessary, I had another 
made, shown in Fig. 231. It is the ordinary Smith's pessary, with 
an oblong cup on the upper 
anterior portion of it, which ^ 
fits over the fistula, and collects 
the urine and guides it out to 
a urinal. In artificial fistula, 
made in the center of the va- 
gina, this pessary answers a 

mn^f valnn"hlp -nnv-nnQP ^^^ 231.— Skene's iirinal cup-pessary, a, rep- 

mOSt VamaOle purpose. ^ ^ ^^^^^^^ ^^^ posterior portion which sur- 

I was led to devise this rounds the cervix uteri ; 5, the cup ; and c, 

way of relieving patients with *; T^^T"^' "" "™' '™™ "" 
vesico-vaginal fistulge by hav- 

mg one under my care who was in no condition to be operated on 
49 




748 DISEASES OF WOMEN. 

for the cure of fistula, owing to general ill-health. She also had 
severe vulvitis, and the urine constantly passing over the inflamed 
surface drove her almost insane. Her suffering was terrible ; so to 
relieve her until I could operate I had made the perforated stem 
globe-pessary, or whatever one may see fit to call it. 

I come now to what I believe to be another important part of 
the treatment of these obstinate cases. I allude to drainage by 
means of the seK-retaining catheter. Tears ago I had a very trou- 
blesome case of cystitis, which I faithfully tried to relieve by all the 
means at my command, but without success. My patient was 
obliged to urinate every fifteen or twenty minutes, day and night, 
and the pain and want of rest w^ere fast wearing her out. In the 
hope of securing rest at night I introduced a Sims's self-retaining 
catheter with a rubber tube attached, to convey the water to the 
urinal. The result was very gratifying. She could sleep well, and 
gained in health and strength rapidly, and the cystitis gradually 
improved. Since that time I have resorted to drainage by catheter 
in cases which resisted the ordinary treatment. 

A description of this plan of treatment will be found in the 
" Proceedings of the J^ew York Obstetrical Society," recorded in 
the " American Jom-nal of Obstetrics," for February, 1874. This 
method has been successfully practiced by Hunter McGuire, a com- 
plete history of his case being published in the " Richmond and 
Louisville Medical Journal" for June, 1874. Dr. McGuire took a 
piece of tubing about twelve inches long, and made holes in about 
four inches of the end of it with a shoemaker's punch. He passed 
a silver tube into the bladder, and then pushed the gum tube through 
it until the perforated four inches were coiled in the bladder. This 
was retained in place by tapes fixed to the tube and to a bandage 
passed around the patient's body. The tube became obstructed by 
mucus, but was easily cleared by injecting warm water through it. 
But this long piece of tubing being frequently expelled by the blad- 
der, the doctor tried a shorter piece, and found it was more readily 
retained. The patient after a time went about and attended to her 
household duties while wearing the tube, and in about four months 
made a perfect recovery. 

This method of drainage is an improvement on Sims's catheter, 
but still is not all that we require. Since my first case I have found 
that a good self-retaining catheter for this purpose is Holt's, made 
of perfectly flexible rubber, and, in place of an eye in the point, is 
cut into strips near the end, and made to spread out hke an umbrella 
(Fig. 232). 



ORGANIC DISEASES OF THE BLADDER. 



749 




Another instrument for drainage is a catheter devised by Prof. 
Goodman, and described in the " Richmond and Louisville Medical 
Journal," for February, 
1869, as being used in the 
treatment of vesico-vaginal 
fistula, and I have recently 
learned that he has used it 
for years in treating cystitis. 
The following is Dr. Good- 
man's description of his cath- 
eter : " It is about two inches 
in length, and bent to cor- 
respond to the curvature of 

the urethra ; at the lower or ^i«- 232.— Holt's catheter, with its modification. 

external end there is a button ten sixteenths of an inch in diameter, 
and at the other, or external, end a shouldered, cup-shaped expan- 
sion, varying from five sixteenths to seven sixteenths of an inch in 
diameter, and beveled on the convex aspect of the instrument, in 
order to make it easier of introduction, and perforated with a num- 
ber of small holes. The stem, intervening between these two por- 
tions, is one and one half inch in length, a quarter of an inch in 
diameter, with as large a bore as is compatible with the requisite 
strength. This catheter is self -retaining in all positions of the pa- 
tient; first, by reason of the bulb at its upper extremity, which 
passes beyond the urethra into the bladder ; second, on account of 
its curved shape ; and third, in consequence of the button being 
overlapped and grasped, as it were, by the vulva. At the lower end 
there is a slight projection, or knob, over which an India-rubber tube 
may be slipped, this being inserted into a bottle at night, or into a 
urinal when the patient is up ; her person may thus be kept per- 
fectly clean." I like this instrument for the purpose of draining the 
bladder, when the patient can tolerate it; but I believe that the 
sharp point of the conical end which rests in the bladder is objec- 
tionable, and I can see no good reason 
for having it so. I had the point 
made larger and rounder (Fig. 223), 
and found that it answered certainly 
as well, and was easier to introduce. 
In drainage by any method it must 
be remembered that the instrument should be frequently removed 
and cleaned, and the bladder occasionally be washed out at the same 
time. 




Fig. 233. — Skene's modification of 
Goodman's self -retaining catheter. 



750 DISEASES OF WOMEN". 

Fortunate it is that we have this method of treatment now at our 
command. By this means we can restore to health and comfort 
many of those cases which have hitherto been considered hopeless. 

I believe that a normal condition of the urethra is a prerequisite 
to drainage. When there is tenderness of the urethra, the patient 
can not tolerate the catheter ; this form of treatment would be more 
popular if this point had not been overlooked. 

Where there is hsemorrhage into the bladder, the rules already 
given are to be followed. 

In cases of exfoliation of the whole or a part of the mucous mem- 
brane of the bladder, and the organ is evidently trying to expel its 
contents, the urethra should be sufficiently dilated to allow the mass 
to pass, or it may be removed by the forceps, if this can be done 
without force. After its extraction antiseptic and disinfectant meas- 
ures should be resorted to. Injections of lime-water, weak solutions 
of carbolic acid or salicylic acid should be used, and the organ 
washed out once or twice daily with warm water. Above all, urine 
should not be permitted to remain in the tender organ for any length 
of time. 

In passing the catheter, especially in cases where the bladder is 
bound to neighboring organs, care should be taken to let no air enter, 
for Winckel has seen vesical catarrh follow its introduction, and 
makes it a point, even after using Rutenberg's apparatus, to wash 
out the organ with some antiseptic. 

Prognosis. — In acute cystitis occurring in a healthy subject the 
outlook is good, recovery being usually attained in from one to three 
weeks. When occurring in the course of pregnancy, or after de- 
livery, the prognosis is not so good, there being a tendency for the 
disease to become chronic, and, even if cured, it leaves a weak state 
of the organ afterward. The prognosis in diphtheritic and croupous 
cystitis depends mainly on the systemic disorder, and is, therefore, 
grave. 

When due to displacements of the gravid uterus, the prognosis 
will, of course, depend on the ability to replace the womb. In can- 
cer of the womb, vagina, anterior vaginal wall, or of the bladder it- 
self, the prognosis is the same as in malignant disease generally. In 
chronic cystitis, with ulceration, the prognosis is very serious ; for, 
with the tendency to haemorrhage, extension to the peritonseum, 
perforation, blood-poisoning, with low systemic condition, extension 
to the renal pelves, and destruction of one or both kidneys, a fatal 
termination comes sooner or later, and may come when we least 
expect it. 



J 



ORGANIC DISEASES OF THE BLADDER. Y51 

About one lialf of the cases of exfoliation of the vesical mucous 
membrane have recovered. Gangrenous inflammation, involving, as 
it usually does, all the coats of the bladder, is the most speedily and 
certainly fatal of all the forms of cystitis. 

Hygiene. — There are certain points to be considered in the man- 
ao:ement of all cases where, from certain circumstances, vesical dis- 
ease is to be expected, and also where it already exists. 

In pregnant women, where the pelvic organs are constantly tend- 
ing to congestion, attention should be given to the patient's circula- 
tion ; friction to the legs, feet, and arms ; daily warm baths ; mod- 
erate exercise, alternated with periods of rest in the recumbent 
position, and astringent or saline vaginal injections should be em- 
ployed. Upon the least suspicion of malposition of the uterus, that 
organ should be examined, and, if malposed, replaced. The diet 
should be bland and unirritating, yet nourishing, and any indigestion 
corrected as speedily as possible. An occasional saline laxative will 
prove of use when there is constipation. Tonics will be found serv- 
iceable in some instances. 

In women not pregnant, where there is a tendency to vesical dis- 
ease, the same plan should be followed, with the addition of injec- 
tions of water, as hot as can be borne, into the vagina every night, 
as recommended by Dr. Emmet. Not less than a gallon should be 
used. Where from any cause retention exists, or there is a tendency 
thereto, the urine should be drawn carefully with a soft catheter, 
well soaped, being sure that the catheter i^ perfectly clean, and that 
no air is permitted to enter the viscus for the reasons already given. 
Winckel believes that in every institution for lying-in women each 
patient should either have a new catheter assigned to her, or one 
rendered absolutely clean by some efficient chemical process. To 
the enforcement of this rule Winckel attributes the great exemption 
from vesical inflammation enjoyed by the patients in the Dresden 
House for Child-bearing Women. 

I must fully indorse the teaching of this great authority. I have 
seen so much bladder trouble brought on by the careless use of foul 
catheters that I have come to look upon clumsy operators and un- 
clean instruments as the most common causes of cystitis. 

In weakness of the detrusor vesicae (which is not an uncommon 
affection in pregnant women), Winckel has achieved great success 
with injections of simple warm or medicated water into the bladder. 

In irritable bladder, with a tendency to congestion, a solution of 
borax may be injected with good results. 

Every woman, even at the risk of disturbing company or neglect- 



752 DISEASES OF WOMEN. 

ing important duties, should evacuate the bladder regularly, and 
never long resist the desire to urinate. 

ELLUSTKATIVE CASES. 

Chronic Cystitis with Intermittent Drainage ; Death from Perfora- 
tion of the Bladder. — The patient was under my care from November 
9, 1869, to February 10, 18T0, while sufiering from a cystitis, which 
began after one of her confinements several years before. At that 
time she had a well-marked cystitis of the pui'ulent variety. She 
was treated by injections — the method in vogue at that time — with 
some benefit. I also employed drainage part of the time by intro- 
ducing a catheter in the evening, and letting it remain all night. 
This gave her great relief, and permitted her to sleep — a blessing 
which she had not enjoyed for several years. She was improving 
in her general health, although her local disease remained about the 
same, or at least only a little improved. She expected to return for 
further treatment, but, her husband becoming paralyzed, she was 
obliged to give up the care of herself to look after her family. From 
that time up to July, 1882, she continued to suffer tortures during 
the day, while she was obliged to be up and around attending to her 
household duties. At night she obtained relief by wearing the cath- 
eter, which she had continued to use ever since she was taught to do 
so, twelve years before. Her sufferings were almost beyond descrip- 
tion, but, having an iron constitution and extraordinary will-power, 
she managed to live until the summer of 1882. During June and 
July of that year she failed more rapidly. Having heard of dilata- 
tion of the urethra as a cure for cystitis, she urged her physician to 
try that operation. He did so, and repeated the operation one week 
later. The only effect of this treatment (as stated in the notes of 
her history, which I obtained) was to reduce the number of evacua- 
tions from one hundred and sixty to one hundred in twenty-four 
hours. Her physician then injected her bladder in the hope of re- 
lieving the inflammation and also overcoming the contraction, which 
was very marked. Immediately after the first and only injection she 
was seized with violent abdominal pains, and rapidly developed a 
peritonitis, which proved fatal on the second day. 

On post-mortem it was found that the bladder was adherent to 
all the viscera around it, the result, no doubt, of a former pericys- 
titis. Upon the posterior wall of the bladder, and directly opposite 
the urethra, there was a nipple-like projection outward, with an 
opening at its apex large enough to admit a lead-pencil. This pro- 
tuberance had been produced by the long use of the hard catheter. 



OEGANIO DISEASES OF THE BLADDER. Y53 

The instrument had worn through the inner walls of the bladder 
until the parts had become less resistant ; it then pushed the remain- 
ing muscular tissue and peritonaeum outward, and formed, the nipple- 
like projection. At the time of the fatal attack, the catheter had 
made its way through all the coats of the bladder except the thick- 
ened peritonaeum. The rupture of the peritonaeum was caused by 
the injection. That was the belief of the physician in attendance, 
and the history points definitely to the same conclusion. The blad- 
der was firmly contracted and in distensible ; its retaining capacity 
did not exceed half an ounce. The muscular wall was over half 
an inch thick ; the mucous membrane was entirely destroyed by the 
inflammation. 

Purulent Cystitis; Recovery after Two Years' Treatment. — This 
patient w^as a lady possessing a remarkably good organization. She 
was married, and had one child. Her age was thirty when her illness 
began. While riding horseback she was thrown off, and sustained 
some apparently slight injuries. Her health up to this time had been 
very good, but from the time of her accident — September, 1878 — she 
had symptoms of cystitis. She was residing in the far West at the 
time of the accident, and, as 1 did not see her for several years after, 
and have not been able to correspond with the surgeon who then at- 
tended her, I do not know the relation which the injury sustained at 
that time bears to the development of the cystitis. I only know that 
the one followed the other immediately. The cystitis persisted, and 
the constitutional symptoms increased from time to time. She then 
returned from the West to New England to be under the care of her 
father, who is a physician of known ability and large experience. 
He gave her every attention, and placed her in the care of a neigh- 
boring physician, who has a high reputation as a gynecologist. With- 
out giving full details of her treatment at that time, I may fairly 
state, upon information received from her father and her physician, 
that all the recognized means of treatment were tried, including 
complete dilatation of the urethra on two occasions. The cystitis 
was not at all relieved by the treatment, and the constitutional symp- 
toms increased continuously, until she became confined to bed. Hav- 
ing a highly sensitive nervous system, she suffered greatly from want 
of sleep and the constant pain of cystic tenesmus. I first saw her 
in consultation about a year from the time when she was first taken 
ill. It was then that this much of her history was obtained. She 
continued under treatinent for six months longer, and, at the end of 
that time, she consulted one of the best known and most worthy 
authorities in New York. He advised cystotomy and drainage for 



754 DISEASES OF WOMEN. 

six months or longer, stating at the same time that, in view of the 
failure of her former treatment to give relief, there was nothing else 
left to be done. She dechned to submit to the operation at that 
time. Her father sent her to me about two and a half years later. 
At that time she was obliged to urinate about every hour, night 
and day. She suffered from constant tenesmus, and her nervous 
system was greatly debilitated. Dr. McCorkle examined the urine 
for me, and found that it contained a large quantity of pus, and 
that there was a remarkable absence of epithelial cells. The doctor's 
report was that the specimen was pus, containing a small quantity 
of urine, and evidently came from a bladder which had entirely lost 
the upper layer of its mucous membrane. The diagnosis then made 
was chronic purulent cystitis. It appeared to me that the case was 
one which called for cystotomy ; but, knowing the objection of the 
patient to that operation, treatment was undertaken, and the results 
soon gave some slight encouragement. The constitutional treatment 
was at hrst chiefly tonic in character, and subsequently she took sahne 
waters, lithia waters, bromide of lithia, and, finally, buchu, benzoin, 
tar, turpentine, and the like. These last preparations, however, did 
not help her, and were not long continued. The local treatment 
was at first instillations of a warm solution of borax. Half an ounce 
was instilled at a time, and repeated until from eight to twelve 
ounces were used at each treatment. The instillations were always 
made with very low pressure. As the sensitiveness of the parts 
diminished, the quantity used was increased up to one ounce, but 
never beyond that. Three months of this treatment showed im- 
provement. There was less pain, and the patient's general health 
had improved considerably. About this time nitrate of silver was 
used, and, later, sulphate of zinc in solution of various degrees of 
strength, but this always caused pain. Indeed, the suffering caused 
by this kind of treatment was great, and the benefit which followed 
being very little, it was given up. I then began to use instillations 
of an infusion of hydrastis Canadensis, containing a small quantity 
of salicylate of soda, which was used to prevent decomposition of 
the infusion. I am now satisfied that the salicylate was of value in 
its effect upon the suppurating mucous membrane. The hydrastis 
was very faithfully used, first by myself, and subsequently by the 
patient, who made the instillations with unusual intelligence and 
care. The result was a gradual diminution of the pain and lessening 
of the frequency of urination. The pus diminished in quantity, and 
simultaneously young epithelial cells appeared in the urine, and in- 
creased in number as the pus diminished. At the end of one year 



ORGANIC DISEASES OF THE BLADDER. 755 

of treatment the local and constitutional symptoms had all disap- 
peared. The urine was normal, and the patient had fully recovered, 
excepting that she was obliged to urinate about every four hours. 
This was owing to contraction of the bladder. To overcome this, 
gradual distention was practiced. The patient was directed to re- 
tain her urine until discomfort, not pain, was felt. Injections were 
used, each time distending the bladder a trifle more, always stopping 
short of causing pain. About two years from the time she first 
came under my care she was perfectly cured of the cystitis, and had 
regained her normal retaining power. Four more years have passed, 
and there is not the slightest evidence of any return of the former 
affection. 

Cystitis treated by Cystotomy without Benefit. — This lady, thirty- 
four years of age, is married, and had four children. She is said to 
have had retroversion of the uterus, which was held in its abnormal 
position by adhesions. She was treated for this displacement in the 
Woman's Hospital of New York, so she said, and, while under treat- 
ment, a cystitis was developed, which continued until I saw her. 
After leaving the hospital, she became pregnant, and her sufferings 
increased. Two years ago, when her last child was four weeks old, 
she consulted a physician here in Brooklyn, who advised cystotomy, 
and soon after he performed the operation, using the cautery. She 
experienced some relief from the operation, but she still suffered 
very acutely. Being led to hope that in time the operation would 
cure her, she bore her afflictions for nearly a year, when she con- 
sulted me on the 5th of September, 1881. I then found her to have 
the tubercular diathesis, rather well marked, but there was no appar- 
ent disease of the lungs at that time. The vesico-vaginal fistula 
made by the operation was large enough to admit the little finger, 
and the drainage of the bladder was quite complete. Yet, strange 
to say, she had constant pain in the bladder, and a desire to urinate. 
These symptoms I found to be due to inflammation and ulceration 
of the urethra and bladder below the fistula. The disease at this 
location caused pain and irritation, which provoked reflex action, 
such as that which arises from the presence of urine in the bladder, 
but in a much greater degree. General tonic treatment was advised, 
and local treatment employed to relieve the inflammation of the 
urethra and neck of the bladder. Locally, she improved slowly. 
The pain and vesical tenesmus subsided almost wholly, but she has 
not yet recovered completely. My object was to cure the local dis- 
ease, and then close the fistula. This I shall never be able to do. 
While the local disease is improving, she is developing phthisis pul- 



756 DISEASES OF WOMEN. 

monalis, wMch precludes all thought of operating to close the fistula. 
The facts in this history, which I trust will be borne in mind, are, 
that this patient was of a tubercular organization ; that cystotomy 
did not cure her cystitis and urethritis, nor relieve her suffering to 
any marked extent. 

Cystotomy for the Cure of Cystitis without Benefit; Death from 
Phthisis following Pneumonia contracted while under Treatment. — Six 
years ago I had a case of cystitis under observation, which illustrates 
the same facts in pathology and therapeutics as in the case just re- 
lated. 

I shall give a very brief outKne of the history simply to show the 
result obtained by another method of doing the same operation. 
This patient was a married woman, who had several children. She 
was of a highly nervous temperament, and came from a tubercular 
family. She consulted me for cystitis, the cause of which is not 
recorded in her history. I treated her with injections for several 
months without benefit. I also dilated her urethra, with the same 
result. In fact, I believe she rather grew worse, in place of better, 
while under my care. Her general health failed noticeably at any 
rate, and she gave signs of a tubercular deposit going on in her 
lungs. Her friends urged her to enter the Woman's Hospital in 
New York. She did so, and was under the care of Dr. Emmet, 
who performed cystotomy, which he did by incision and keeping 
the fistula open, first by his glass tube, and afterward by dilatation 
with the finger. After the operation, she had an attack of pneu- 
monia — at least, she told me this when she returned from hospital. 
Upon her return home, I found that she had been much relieved of 
her most urgent symptoms by the operation. Still, there was cys- 
titis remaining, and she had vesical pain and tenesmus. The tuber- 
cular disease of the lungs had progressed rapidly, and that portion 
of her lung which was involved in the pneumonia never cleared 
up. Her strength rapidly failed, and she died before the cystitis 
subsided. 

CROUPOUS AND DIPHTHERITIC CYSTITIS. 

Croupous and diphtheritic diseases of the bladder are very rare, 
and therefore require but a brief notice here. From the difficulties 
that have existed in the detection of the exact pathological conditions 
in diseases of the bladder, we may presume that mild attacks of these 
affections have been overlooked or not correctly diagnosticated. But, 
even granting this, we are compelled, from the few recorded cases, 
to believe that croup and diphtheria of the bladder seldom occur. 



I 



ORGANIC DISEASES OF THE BLADDER. 757 

What little exact knowledge we possess on this subject has been 
obtained to a great extent from post-mortem examinations, and 
from this statement it will be inferred and correctly too, that tliese 
diseases, especially diphtheria, tend to end fatally. 

From the names employed one would naturally suppose that 
these affections were exactly the same as the diseases of the mucous 
membrane of the air-passages, known as croup and diphtheria. Be 
that as it may, it will suffice for my present purpose to have it un- 
derstood that in these diseases of the bladder there is developed an 
exudation or membrane like of that of croup or diphtheria. 

The pathology of the local lesion in these two diseases differs 
only in the depth of tissue involved and in the character of the 
membranous formation. Thus in croupous cystitis, the false mem- 
brane, while moderately adherent, is usually on the surface, covers 
the whole or most of the mucous membrane of the bladder, and 
sometimes portions of the outer genitals, and is fibro-epithelial in 
structure. 

The diphtheritic membrane, on the contrary, dips deeply into 
the mucous membrane of the bladder, exists usually in scattered 
patches, and is denser and more fibrous in character, its interstices 
being filled with little rounded cells and some fatty and granular 
matter. 

Exfoliation of the affected portions of the vesical mucous mem- 
brane usually results from this diphtheritic inflammation, as in the 
analogous affection in the throat. When the membrane comes 
away, ulcers of varying size and depth are left to mark its former 
site. The destructive processes are not alone confined to the mu- 
cous and submucous tissues, but in some cases involve the muscular 
coat of the organ. The whole vesical surface, not covered with the 
membranous exudate, is of a deep-red color, and in some places 
ecchymotic, especially about the exudation. The inflammation is 
truly acute, and passes rapidly from the stage of mucous exudation 
to that of epithelial exfoliation and pus formation. 

Symptomatology. — The symptoms in no way differ from those of 
acute cystitis, save that as a rule they are more intense and the con- 
stitutional symptoms are more severe. The nervous system is usu- 
ally profoundly affected. There is pain before, during, and after 
micturition — pain that may be purely local, felt in the outer genitals, 
or radiate in all directions. 

When the shreds of broken-down membrane separate, they may 
block up the urethra, and cause retention and decomposition of 
urine. Retention, however, may be produced at any time by in- 



758 DISEASES OF WOMEN. 

tense inflammator j tumefaction of the urethra, which is often in- 
volved. 

This exfoliation of false membrane must not be confounded 
with the sloughing of the mucous membrane of the bladder caused 
by pressure from overdistention or very severe inflammation. 

As the symptomatology of these diseases is very much the same 
as those of acute and chronic cystitis, it may be best not to enlarge 
upon them here, as that would involve much useless repetition. 

Diagnosis. — Microscopical examination of the urine, but more 
especially of the tissue shreds, will afford much reliable information. 
When a membrane is found consisting of fibrillse interspersed with 
numerous small nucleated cells, having undergone fatty degenera- 
tion, and involving the superficial mucous or muscular layer, the case 
may be set down as one of diphtheritic cystitis. The urine rarely 
affords any positive information ; and really it is useless to attempt 
to make a differential diagnosis between these diseases and ordinary 
cystitis in which there is much destruction of tissue. 

Thus far I have had no opportunity of examining croupous or 
diphtheritic disease of the bladder with the endoscope, and can not 
say how much information could be obtained in this way. I pre- 
sume that much could be gained by this instrument, and I base this 
opinion upon the examination of several cases of catarrhal and 
croupous inflammation of the rectum. In these cases the distinction 
between catarrh and croup could be easily and positively made by 
the endoscopic appearances, and I believe that what has been done 
in determining rectal disease could be accomplished in diseases of 
the bladder. 

In these cases the vesical walls are very fragile, and this should 
be borne in mind in using either catheter or endoscope. This con- 
dition would preclude the distention of the bladder with air and 
examination with Rutenberg's apparatus. 

Prognosis. — This is very grave indeed. 

Treatinent. — This, in brief, is to keep the patient perfectly quiet, 
to let the diet be the most sustaining, the drinks free and bland, and 
to keep the bladder pretty well emptied, to allay the pain and spasm 
by the judicious exhibition of narcotics, preferably by the vagina, in 
suppository. The bladder should be washed out daily with warm 
water, containing a little of Labarraque's solution or a little carbolic 
acid. Much relief of both pain and spasm will thus be afforded, even 
when the inflammation is at its highest. 

Tissue shreds should be removed as soon as their presence is as- 
certained. 



ORGANIC DISEASES OF THE BLADDER. 759 



CYSTITIS WITH EPIDERMOID CONCRETIONS. 

This is a very rare affection of the bladder, and I only mention 
it as a pathological curiosity. Rokitansky supposes it to be due to, 
or a sequence of, chronic cystitis. It consists in an unusually rapid 
formation of epithelium by the vesical mucous membrane, resulting 
in the sliedding of quite large white, shining plates or bodies of this 
caked scale. The following case, related by Lowenson (1862), is 
thus given by Winckel. The patient spoken of by him, suffered 
from mitral stenosis, and came into hospital in a moribund condition. 
After death her bladder was found to be enormously dilated. From 
it were taken a great number of small, rounded yellow masses, lying 
between a number of plates of dullish color, the general appearance 
being that of yellow pea-soup, with some of the hulls left in. The 
whole of the internal surface of the bladder was covered with flakes, 
many of them having these little balls interposed and superimposed. 
Their diameter varied from one twenty-fifth to one half inch. These 
attached flakes were tolerably firm and bright, something like mother- 
of-pearl. From the mucous membrane itself, after removal of these 
flakes, pieces of membrane could be stripped off. Except in these 
places the mucous membrane seemed normal. The urethra and 
ureters were normal, but the kidneys were in a condition of granu- 
lar atrophy. 

On microscopic examination it was found that the young, often- 
times fatty degenerated epithelial cells (in the commencement), as 
they approached the surface, took on gradually all the changes of 
the very large epidermic cell, becoming non-nucleated and granular. 
The little balls consisted of grains of fat, calciform concretions, lit- 
tle nuclei, and epidermic cells. There was considerable stearine but 
no cholesterine. Reich claims lately, however, to have found the 
latter in the vesical mucous membrane of a man fifty-six years old, 
who suffered from catarrh of the bladder. 

Treatment — Of course I have no experience, never having seen 
a case, but on general principles I would suggest that the treatment 
would be to relieve any inflammation or irritation that may be pres- 
ent, the exhibition of alkalies and arsenic (in small doses) by the 
mouth, daily washing out of the bladder, removing all scales or 
plates that form, and the application of a strong alkaline solution to 
the diseased surface. 

I am unable to give the symptoms of this disease. The same may 
be said of the diagnosis. I presume, however, that an examination 
of the urine would enable one to determine the nature of the trouble. 



CHAPTER XLII. 

KON-mFLAMMATORY DISEASES OF THE BLADDEK. 
DISLOCATION OF THE BLADDER. 

II. Non-inflammatory diseases of the Madder. These are : 

1. Dislocations. 

2. Foreign bodies. 

3. Rupture. 

1. Dislocations. — These may be of six kinds : {a) upward ; (^) 
backward ; {&) forward ; {d) lateral ; {e) downward ; in addition to 
these, we may have (/") inversion of the bladder. 

Some of these are, even in their worst form, not true disloca- 
tions, but represent some hindrance to the proper distention of the 
organ or its position when distended. Of all dislocations, the most 
important are the upward, backward, and downward. All of them, 
however, interfere more or less with the vesical function. Marked 
dislocation of a healthy bladder often gives rise to less disturbance 
than slight dislocation of an already irritable organ. 

Dislocations of the bladder have various causes, the most com- 
mon and troublesome being abnormalities of structure and position 
of the uterus and vagina. 

As a matter of fact, these dislocations are usually secondary to 
some affection of the other pelvic organs. This necessitates a de- 
scription of their causes as well as the conditions under which they 
occur, thus deviating from the general order followed in this work. 

(a) Dislocation Upward. — The upward dislocation of the bladder 
may be caused by the dragging up of the organ by the gradual rising 
from the pelvis of the gravid uterus. This, however, is a rare affec- 
tion, and only occurs, I think, in cases where there has been previous 
inflammatory action. in the pelvis, gluing the parts together. In 
most pregnancies the bladder retains what is, under the circum- 
stances, its normal position. Bands of adhesion passing from the 



NON-INFLAMMATORY DISEASES OF THE BLADDER. 761 

bladder to the various abdominal and pelvic viscera may, when short- 
ening takes place, produce this dislocation. It may also be produced 
by ovarian tumors, and, in some cases of uterine retroflexion and 
retroversion. The dislocation accompanying the last two affections 
is, however, usually more backward than upward. 

The other most probable causes are tumors about the neck or 
base of the organ, tumors of the cervix uteri, pelvic deformities, and 
pelvic exostoses. 

The symptoms are usually those of irritable bladder. In some 
cases of pelvic tumor the pressure on the neck of the bladder, forc- 
ing it against the pubes, produces retention. This is purely me- 
chanical. In other cases, where there is no obstruction to the out- 
flow, but pressure on the bladder, there may be incontinence ; and, 
again, from traction on the muscular walls, patients are unable to 
contract and expel the vesical contents, and retention results. 

I saw a case, in consultation with Dr. A. W. Ford, of Brooklyn, 
in which the patient had retention of urine, so that she could not 
urinate while standing, but was compelled to lie down before the 
bladder could be emptied. The retention lasted one week, and was 
brought on by the efforts to urinate, which wedged the uterus in the 
pelvis, and compressed the neck of the bladder. She was relieved 
by urinating while on the hands and knees. 

(5) Dislocation Backward. — This dislocation stands next in order 
of importance and unfavorable results to downward dislocation. It 
may be caused by tumors of the abdomen or by pelvic adhesions, but 
the most frequent cause is backward dislocation of the uterus, such 
as retroflexion and retroversion. Retroversion affects the bladder 
in the same manner as prolapsus, except when the uterus is very 
much enlarged, and is thrown backward and impacted in the pelvis, 
so that the cervix presses flrmly on the urethra. In such cases urina- 
tion is impossible. Examples of this are seen in retroversion, occur- 
ring in the early months of pregnancy or after delivery. Schatz gives 
a case due to retroflexion of the uterus during pregnancy, produc- 
ing the same trouble in the bladder as retroversion. 

Winckel saw a case in the body of a non-puerperal woman, in 
which the uterus was lying almost horizontally in the pelvis, with 
its fundus adherent to the rectum. That part of the bladder that 
was drawn most backward had a diverticulum, containing a calcu- 
lus. The neck of the bladder was fastened down posteriorly by 
tight bands of adhesion that passed from it over the uterus to the 
rectum. 

In retro-displacements of the bladder, with no pressure on the 



762 



DISEASES OF WOMEN. 



vesical neck, the symptoms are usually those of irritation, causing 

frequent urination and tenesmus. 

I give here the following cases, as they are of interest, and 

may serve to fix more clear- 
ly in the mind the general 
points. 

ILLUSTEATIVE CASES. 

The first is a case of 
chronic retroversion of the 
uterus, causing marked vesi- 
cal trouble in a nervous wom- 
an. The cause of the blad- 
der trouble is here double : 
„^. ~ . - ^, ., ^ first, vesical neurosis, and 

234. — Ketroversion of the gravid uterus ' . ' 

(after Schatz). The bladder pulled upward SCCOud, a displaced UteruS. 

Mrs. H., aged thirty-six. 




Fig. 



and backward, and the urethra, u, put great- 
ly upon the stretch. 



Mariied five years, and a 
widow three years, of a marked nervous temperament. Has never 
been pregnant. Menstruation always normal, and general health fair 
in early life. Her general system has been much reduced by nursing 
her husband, who died of phthisis. Nervous system also much im- 
paired. When first seen, all the functions except those of the blad- 
der were performed well. She suffered night and day from frequent 
urination, but there was no pain either during or after the act, unless 
she tried to hold her water for a few hours, when there was great pain 
after the completion of evacuation. Nervous excitement, pleasant 
or unpleasant, made the trouble much worse. Her urine was normal. 

On examination, complete retroversion of the uterus was found, 
with shortening of the anterior vaginal wall ; the bladder was much 
contracted, but otherwise normal. The uterus was restored to its 
place, and held there by a pessary. Hydrobromic acid in thirty-min- 
im doses was given four times a day. She made a rapid recovery. 

The next is a case of vesical tenesmus and partial retention from 
a sudden retroversion of the uterus. 

Mrs. G., aged forty-three, the mother of four children. Widow 
for several years. She was a strong, healthy lady, and had been on 
her feet all day attending to her household duties, and in the even- 
ing, while hanging some pictures, slipped from a chair, and fell 
heavily to the floor, striking on her feet. She was at once seized 
with a desire to urinate, and soon after pelvic tenesmus came on. 
The desire to urinate was constant, and, after strong expulsive 



¥OX-mFLAMMATORY DISEASES OF THE BLADDER. 763 

efforts, she was able to pass a little urine from time to time, but 
without relief. The bowels became distended and tympanitic. On 
the following daj she was ordered anodynes, but they gave very 
little relief. 

On the next day she was examined, and the uterus w^as found to 
be completely retroverted, and the bladder full, but not overdis- 
tended. Keplacing the uterus gave her great relief at once, and she 
has remained well and free from all bladder trouble since the acci- 
dent occurred, some two years ago. This was a case of acute retro- 
version of the uterus, producing an intensely painful affection in a 
normal bladder. 

(c) Dislocation Forward. — Forward dislocation of the bladder, 
unless it be through the open abdominal walls, is very rare. Some 
change in its shape from pressure of organs or tumors from behind 
may occur, but this is really not a true displacement, except in some 
rare and marked cases. The most frequent cause is pressure from 
the anteverted and enlarged uterus in either the virgin or puerperal 
state. Ante version of the uterus usually causes frequent urination, 
perhaps as much so as prolapsus ; but whether this frequency is due 
to the fundus uteri resting on the bladder, or to the supersensitive- 
ness of the whole pelvic organs, which usually accompanies this dis- 
location, I have not always been able to determine. I have been in- 
chned to the belief that the latter was the case. In this displace- 
ment (anteversion) the uterus is generally enlarged and elevated, so 
that the body and fundus rest upon the bladder, and impede its dis- 
tention. 

True dislocation of the bladder forward is the rarest of all dis- 
locations, only three cases being on record. It has been variously 
called ectopia of the uniissured bladder, ectopia vesicae totalis, and 
prolapsus vesicae completus per iissuram tegumentorum abdominis. 
The first name is too vague, the last best of all, but rather lengthy 
for every-day use. 

The three cases on record are by G. Yrolik, StoU, and Lichten- 
heim. In all these the bladder was protruded through a small slit 
in the abdominal wall, and appeared as a bright-red, romided tumor 
at the lower and anterior part of the abdomen. In Lichtenheim's 
case only was the tumor reducible. The pubic bones were sepai'ated 
about two inches. The urine could be retained perfectly, and the 
patient was able to micturate in a small stream. Microscopical ex- 
amination of the outer covering of the bladder-walls proved it to be 
mucous membrane, like that lining the interior of the organ. 

In G. Yrolik's case, according to Winckel, there is doubt as to 
50 



764: DISEASES OF WOMEX. 

whether it was a true vesical ectopia. He believes it to have been 
a gaping of the fissured abdominal walls over a dilated urachus, the 
latter communicating with the bladder bj a small opening. 

In Lichtenheim's patient no operative measures were thought of, 
for, beyond a little excessive secretion of the external surface, no 
trouble was experienced. If, however, from the protrusion of the 
tumor or other canse, difficulty in passing or retaining nrine be pres- 
ent, an attempt should be made to close the abdominal fissure. If 
it be large, two or more fiaps may be needed to accomplish the de- 
sired result. The operation is very like that for fissure, already de- 
scribed, only more simple. 

If an operation is not desired or consented to, the patient should 
wear a concave compress, and, by attention to bandaging, keep the 
surface of the organ in as nearly a normal condition as possible. 

{d) Lateral Displacements.— Lateral displacement of the bladder 
is not very often met with. It is generally due to inguinal or fem- 
oral hernia, tumors at the side and base of the organ, and contract- 
ing pelvic adhesions. There is generally more or less distortion of 
the urethra that may hinder the outfiow of urine or prevent the easy 
introduction of a catheter. Irritability may result, but it is not so 
common as in the other varieties, the organ being generally but 
slightly displaced, and, soon getting used to the disturbing cause 
arising from the malposition, produces but little disturbance. 

One case of this kind I have seen which was of interest. The 
patient was a young lady, who had had a pelvic peritonitis, which 
left her with pelvic tenesmus, ovarian pain, and some vesical tenes- 
mus and difiiculty in emptying the bladder. One of my assistants, 
while examining her, found a fluctuating tumor on the left side, 
which he supposed to be an ovarian cyst, but which proved to be 
a left lateral displacement of the bladder fixed in its malposition by 
adhesions. 

Causation. — Its causes are of two kinds — predisposing and excit- 
ing. Of the predisposing, the most common are a loose, flabby con- 
dition of the vesico-vaginal septum, excessive venosity of same (these 
may be due to pregnancy or to a general systemic condition), ab- 
normally capacious vagina, unusually large introitus vaginse, total or 
partial loss of perineal body, and the tendency of the bladder to 
pouch inferiorly as age advances. 

As exciting causes, we have violent expulsive efforts, as in def- 
ecation, lifting heavy weights, and especially child-bearing. The 
latter is probably one of its most common causes, for not only do 
we have expulsive efforts of the most violent kind, but a lax, spongy 



NON-INFLAMMATORY DISEASES OF THE BLADDER. 765 

condition of the vesico- vaginal septum — i. e., the anterior vaginal 
and posterior vesical walls, which are pushed downward before the 
advancing head. 

Another common cause is prolapsus uteri, though in many cases 
the cystocele precedes the prolapse of the womb. Whichever is 
the cause, the one aggravates the other. In slight prolapse of the 
uterus, the vesical symptoms are only those of irritation ; and it is 
a strange fact that the irritation is often as great in the first degree 
of prolapse as in the third. 

Other less frequent causes of cystocele may be tumors in the 
posterior vesical or anterior vaginal wall, stone in the bladder, vesi- 
cal diverticuli, violent efforts at urination, and marked pressure from 
above. 

The bladder begins to sag inferiorly as age advances, and conse- 
quently the tendency to prolapsus advances, as does the age. The 
number of pregnancies may, however, have more to do with the fre- 
quency than the tendency to pouching in old age. 

{e) Dislocation Downward. — I have reserved this malposition to 
the last, because it is the most important. There are various grades 
of the dislocation, the most marked of which is known as cystocele 
vaginalis. 

Pathology. — This affection may be conveniently divided into 
three grades. In the first, there is but a slight bagging of the or- 
gan. In the second, about one half the bladder lies below the nor- 
mal level of the anterior vaginal wall, giving the organ an hour- 
glass shape, the urethra entering the upper segment just above the 
point of partial constriction. In the third or highest grade, the 
whole bladder lies below the level of the normal anterior vaginal 
wall. The urethra in these cases has a direction from above back- 
ward and downward. The ureters in the last two grades are so bent 
and obstructed by pressure, that dilatation and hydronephrosis may 
result. Such instances are given by Phillips, Froreiss, Yirchow, 
Braun, and Winckel. 

The vesico-uterine pouch is, in cases of marked vesical and 
uterine prolapse, greatly increased in size, and may contain a loop of 
intestine. In some rare cases it may become constricted superiorly, 
and exist as a closed sac. 

In chronic cases the vesical mucous membrane becomes hyper- 
trophied, and, in the lower segment especially, congested and a3dem- 
atous. To this may be superadded cystitis and ulceration, which 
often follow in cases of long standing. 

Symptomatology. — In the first grade of downward dislocation 



766 DISEASES OF WOMEN. 

the symptoms are those of irritable bladder, such as frequent and 
sometimes painful urination. When the displacement has existed 
for a considerable time, the bladder seems to accommodate itself to 
the new relations, and the calls to urinate become less frequent. In 
cases in which the prolapsus of the bladder is slight and there is dila- 
tation or prolapsus of the upper third of the urethra, partial inconti- 
nence occurs, a very annoying symptom. Every time the patient 
coughs, lifts a heavy weight, steps suddenly down from the curb- 
stone into the street, or even indulges in a hearty laugh, there is a 
sudden escape of urine. 

In complete prolapsus of the uterus and bladder, we find instead 
of frequent urination, difficult urination, and in the worst cases, re- 
tention. Partial retention always occurs in the marked cases, and 
the urine remaining in the bladder decomposes, and in time causes 
cystitis, which greatly aggravates the patient's sufferings. Such 
cases are very like those occurriug in old men, and due to retained 
nrine by reason of an enlarged prostate gland. 

There is usually a dragging pain experienced in the region of 
the umbilicus, which is due to traction on the urachal cord, and also 
a constant sense of pain and uneasiness, due partly to the vesical and 
partly to the uterine malposition. 

To fully empty the bladder in the worst cases, it is necessary to 
relax the parts by lying down, and then force out the urine by press- 
ure on the vaginal tumor. 

Cystitis is a common secondary affection, and is due to decompo- 
sition of the retained urine, and to chronic congestion with oedema 
and hypertrophy of the mucous membrane. Winckel's experience 
has, however, differed from that of most observers, he having 
failed to find a single instance of cystitis in sixty-eight cases of cys- 
tocele. 

From pressure on the ureters there may result dilatation and 
hydronephrosis, and if marked or long-continued, uraemia. There 
may also be set up that condition known as pericystitis, and the 
lower vesical segment be rendered irreducible owing to the formation 
of adhesions. 

If cystocele occurs in a patient already suffering from cystitis, 
the original trouble is of course greatly aggravated. 

Cystocele may interfere with delivery during childbirth. In 
one such case, McKee, being unable to push a catheter into the 
bladder, punctured the tumor with a lancet, and dehvery was rap- 
idly accomplished. In another case, a certain physician mistook 
the vesical tumor for the bag of waters, and punctured it. 



NON-INFLAMMATORY DISEASES OF THE BLADDER. 767 

Diagnosis. — This is readily made. The patient should be laid 
upon her back, with the thighs flexed on the body. If the tumor is 
already down it should be examined carefully, and also the position 
and condition of the neighboring organs. If possible, a catheter 
should be passed into the bladder, to ascertain if it enters the tumor 
and the direction it takes in so doing should be observed. The 
tumor should be slightly compressed, and notice taken whether the 
urine flows from it through the catheter. An attempt should also 
be made to try to reduce it. The urine should be carefully ex- 
amined for pus, mucus, albumen, epithelial elements, and the amount 
of urea should be determined. 

Prognosis. — The prognosis is generally good ; but in giving an 
opinion the degree of dislocation, the size of the tumor, the condi- 
tion of its mucous membrane, whether it is reducible or not, the 
age of the patient, and the gravity of the producing cause, must all 
be taken into consideration. 

In young patients, Sims, Simon, Hegar, Yerf, and others claim 
to have obtained radical cures. Some of these cures were not, how- 
ever, lasting. Scanzoni claimed that he had never seen an opera- 
tion for this displacement that resulted in a permanent success, and 
that his own operations were by no means satisfactory. My own 
experience entirely accords with that of Scanzoni. 

Treatment. — The treatment consists in reposition and retention. 
The former is easy, the latter hard to accomplish, as prolapsus uteri 
and cystocele generally go hand in hand ; one can not be treated 
without the other. 

Having pushed the uterus up into position, emptied the bladder 
and replaced it, some mechanical ^rr'^^ 

means should be sought to retain "^ J^^^m^^ 

one or both organs in place. mKBT^S^L. 

For the purpose of support- .^^^^^ ^^^ mKm£i^ ^ B^^-^ 
ing the prolapsed bladder I de- mf ^"^^^j^^ ^^^^ 

vised the pessary shown in Fig. It" ~ \ji^r^^^^^^^^^, 

accomplish the obiect fairly well ^i»- 235.— Pessary for prolapsus of the 

, , 1 ' ji • • bladder (Skene). The main portion, a, 

Wnen tne pelvic noor is not m- surrounds the cervix uteri, and b sup- 

iured. ports the bladder and upper portion of 

™* • T n 1 *^® urethra. The other part, c c, joins 

ihlS pessary is adapted and the main portion in front of the uterus, 

introduced in the same way as a ^"^ ^^^"^^ ^^ *^^® posterior walls of the 

•^ vagina. 

retroversion pessary, an account 

of which will be found under the head of the treatment of retro- 
version. 



768 



DISEASES OF WOMEN. 



The facility of introduction and removal is one of the minor, but 
by no means unimportant, qualities of this pessary. 

Several sizes are made, which answer in most of the forms of 
displacement of the bladder ; but a case will occasionally occur in 
which it is necessary to iirst take measurements, and have the in- 




FiG. 236. — Pessary holding up the bladder. 

strument made exactly to suit. This can be easily done. The pa- 
tient is placed on her left side, and after introducing the speculum, 
the uterus and bladder are restored to their proper positions ; then 
a thin strip of sheet lead is bent to the size and shape of the ante- 
rior walls of the vagina and cervix uteri. This form will enable the 
instrument-maker to produce the required size and shape of the 
pessary. I have also devised another form which suits some cases. 
It is like the retroversion pessary 
which I use, but the sides anteriorly 
are made more curved and very 
much thicker than the ordinary one. 
Fig. 237. 

Should a pessary fail to accom- 
plish the desired result and the case 

^row gradually worse and the de- Fig. 237.-Modification of the retroyer- 
^ ^ ^ sion pessary, used in prolapsus oi 

mand for relief become more urgent, the bladder. 




NOi^-INFLAMMATORY DISEASES OF THE BLADDER. 769 

the operation may be performed which is described on page 866 
and ilkistrated in Fig. 2i9, Plate lY. 

HERNIA OF THE BLADDER. 

This injury was first recognized by Dr. Paul F. Munde, and 
described by him in the " American Journal of Obstetrics," June, 
1890, page 614. That it may have been observed by others is pos- 
sible, but it was evidently not understood until thoroughly investi- 
gated by Munde. Guided by the light which he has thrown upon 
the subject, I have been able to comprehend a number of cases 
which were previously obscure, and which, not knowing better, I 
had classified as cases of prolapsus of the bladder. 

The pathology is the same as in all hernial protrusions. There 
is first a giving way of the anterior muscular wall of the vagina in 
the median line, and then the bladder, covered only with the vagi- 
nal mucous membrane, protrudes into the vagina. 

Causation. — There are three causes which I have observed in 
the cases which have come under my observation : 

The first, which occurs less commonly now than formerly, is 
removal of a part of the vaginal wall, colporrhaphy. In time the 
scar-tissue stretches at the site of the operation, and the bladder 
protrudes at the point at which muscular tissue is deficient. 

The second cause is, apparently, a laceration of the muscular 
tissue in the median line during labor. When the hernia is caused 
in this way the urethra and lateral walls are in proper position, but 
at the point of hernia the muscular tissue and fascia are absent. 

The remaining cause is atrophy of the muscular tissue. This I 
believe to occur, because it has been found in women past the meno- 
pause who have not had children, and who have not been subjected 
to any injury which could have produced muscular laceration. 

Symptomatology. — The symptoms, so far as I have observed 
them, are the same as in prolapsus of the bladder. 

Physical Signs. — The physical signs are, when understood, quite 
diagnostic. When the perinseum is retracted, the hernia appears as 
a smooth, hemispherical body, around the base of which the vaginal 
walls are in normal position. With a sound in the bladder, the thin 
vaginal wall, which is reduced to mucous membrane only, is appar- 
ent to the touch. If any doubt exist about the diagnosis, the results 
of treatment will determine whether the condition is that of hernia 
or of prolapse. If it be a prolapsus, which has been treated by the 
use of a tampon or pessary, with rest in a recumbent position, there 
will be a noticeable contraction of the vaginal wall and a temporary 



IQS^ DISEASES OF WOMEN. 

relief ; but no such change occurs as a result of this treatment in 
case of hernia. 

Treatment. — Having failed to relieve hernia by any of the oper- 
ations recommended for prolapse, I was driven to try an operation 
which gave me good results, and that, too, before I understood the 
true pathology of the affection. 

The operation consists in making a small opening in the vaginal 
wall at the junction of the urethra and bladder, and at the lower 
margin of the hernia. Through this opening a probe is passed and 
pushed up to the upper margin of the hernia, between the vaginal 
wall and the bladder. A delicate forceps is then introduced into 
the tunnel made by the probe, and its blades are spread forcibly 
apart. The vaginal wall and bladder are then completely separated 
to the extent of the hernial opening in the muscular layer of the 
vagina. The probe or forceps is held in place and upward pressure 
is made with it. This keeps the bladder in place while traction is 
made upon the vaginal mucous membrane at its upper part. This 
brings the lateral edges of the muscular layer of the vagina together 
and develops a ridge of mucous membrane. Sutures are now intro- 
duced to hold the parts in position. 

The mechanism of this proceeding is the same as in making a 
tuck. The ridge or tuck of mucous membrane projects into the 
vagina hke the segment of a circle, but soon flattens out and over- 
hangs the line of sutures. Care should be taken not to make the 
sutures tight enough to strangle the tissues, but only sufficiently so to 
hold them together until they unite. I have operated in a number 
of cases, and the immediate results are all that could be desired. I 
have had an opportunity to observe but four cases long enough to 
determine whether the cure is permanent or not. In one of these, 
done five years ago, the hernia shows no disposition to return. The 
same is true of all the cases that I have operated upon. The first 
operation was done five years ago, and the last, one year. 

Dr. Munde, in his paper on this subject, commends the opera- 
tion of Stolz, which consists in the removal of the circular portion 
of the mucous membrane which covers the hernia, and the bring- 
ing of the parts together at one central point with a purse-string 
suture. 

I have tried this operation in three cases, and have found that, 
while it appeared to answer the purpose, the scar gave way in time 
and the hernia returned. In fact, the worst case of hernia of the 
bladder that I ever saw followed a similar operation, which was 
done for prolapsus. 



NON-INFLAMMATOKY DISEASES OF THE BLADDEFv. 769* 



ILLUSTKATIYE CASES. 

A patient who had had a number of children suffered from a pro- 
lapse of the bladder and laceration of the perinseum. I performed 
^oeggerath's operation for the relief of cystocele, and obtained a 
good result so far as relieving her for a time. She returned four 
years afterward, suffering as much as ever. I found that the scar 
left after removing the section of the anterior vaginal wall had 
become stretched and thinned out, so that the bladder protruded. 
I vivified the vaginal wall all around the outer edge of the scar, and 
brought the surfaces together and obtained good union. Two years 
after this I found the hernia had again returned. This led me to 
devise the operation which I have described above, and which has 
given me far more satisfaction. 

Hernia following Stolz's Operation. — A patient fifty-nine years old 
had a prolapsus of the bladder and a laceration of the perinsenm of 
sixteen years' standing. I performed Stolz's operation and restored 
the perinseum. She was apparently cured, but two years afterward 
I saw her again, when I found what I believed to be a return of the 
prolapsus, but I now know that she had a vesical hernia. 

Frequent Urination due to Prolapsus of the Bladder. — The patient 
was thirty-two years old, and had given birth to ^yb children. She 
had always been well and strong, and at the time that I saw her she 
was in very good general health. After her last confinement, one 
year previous, she began to suffer from frequent urination. At first 
she obtained relief from emptying the bladder, but subsequently 
the desire to urinate, though not very urgent, was constant when she 
was upon her feet. On lying down she obtained relief and retained 
the urine all night, but upon rising and going about the tenesmus re- 
turned. 

By digital examination I detected a prolapsus of the bladder, 
but only in a slight degree. 

There was considerable relaxation of the pelvic floor and of the 
vaginal walls, but no laceration of either. In all other respects she 
was quite well. The urine was normal. She was ordered to rest 
for a few days, most of the time reclining, and to use vaginal injec- 
tions night and morning of sulphate of zinc, sixty grains to the 
quart of warm water. Afterward a pessary was used shaped like 
Graily Hewett's anteversion pessary, but having the anterior bars 
thickened. 



770 DISEASES OF WOMEN. 

Immediate relief was giv^en by the pessary, and she was able to 
walk and stand as she nsed to in former times. The zinc-donche 
was kept up once a day, and she was cautioned against walking or 
standing too long. At the end of six weeks the pessary was re- 
moved to see if she could do without it. In a few days the old 
symptoms began to return, and the pessary was replaced to her en- 
tire rehef. From this time onward the pessary was changed once a 
month for a smaller one. Seven months afterward the instrument 
was removed, and the injections of the zinc solution continued for 
one month longer. She had no further trouble. 

Prolapsus of the Bladder caused by Laceration of the Perinseum. — 
This lady was forty-one years old, of large form, and had an excel- 
lent constitution ; she had two daughters, the youngest seven years of 
age. For nearly six years she had suffered from vesical tenesmus and 
frequent urination. These symptoms were greatly aggravated by 
the erect position. In fact, for a long time she was quite comfort- 
able while sitting or lying down, especially the latter. Her symp- 
toms gradually increased, and within the past two years she has had 
partial incontinence. Any sudden motion such as is caused by cry- 
ing or sneezing would cause a spurt of urine which was most dis- 
tressing to her. She became quite helpless although in perfect 
health. Being unable to stand or walk for any length of time and 
having partial incontinence she remained in the house all the time. 
She had been treated with all kinds of drugs, but, as might have 
been expected, without any relief. I found that she had a laceration 
of the perinseum, and also a bilateral laceration of the cervix uteri. 
The bladder was prolapsed and the upper third of the urethra pre- 
sented the usual signs of the ordinary cystocele. She was admitted 
to my private hospital, and after having been submitted to prepara- 
tory treatment the cervix was restored. While she was recovering 
frooQ that operation the bladder was kept in place by the tampon, 
and astringent vaginal injections were used. One month later the 
pelvic floor was restored, and as much tissue brought together as pos- 
sible. After the operation the pelvic floor was kept well sup- 
ported with a compress and T-bandage. The astringent injections 
were continued. Six weeks from the last operation she was per- 
mitted to take exercise, but the pelvic floor was supported for two 
months longer. After restoring the pelvic floor it was necessary to 
use the catheter to draw the urine ; that excited some irritation of 
the bladder, but this was relieved by injections of borax and water. 
She made a perfect recovery, and has remained quite well for more 
than four years. 



NON-INFLAMMATORY DISEASES OF THE BLADDER. 771 

Cases of Displacement of the Bladder due to Displacement of the 
Uterus and Causing Retention of Urine. — (D. Berry Hart, M. D., " Ob- 
stet. Jour.," Great Britain and Ireland, August 3, 1880) : 

Case I. — A. B., aged eighteen, was seen in Prof. Simpson's out- 
patient clinic, on account of white discharge and pain on making 
water. Ocular examination of the external parts showed a recent 
laceration of the hymen and glairy discharge from the ostium vaginse. 
On vaginal examination the cervix was found normal in all respects, 
except that the os looked downward and forward ; bimanually, a fluc- 
tuating tumor, reaching up a little above the level of the pelvic brim, 
was felt in front of the partially retroverted unimpregnated uterus. 
The catheter introduced drew off twenty-seven ounces of urine. 

Case II. — Mrs. C. w^as admitted to Prof. Simpson's ward on ac- 
count of retention of urine, necessitating catheterism ; bimanual ex- 
amination showed a large tumor in the hollow of the sacrum, marked 
elevation of the os uteri above the symphysis, and a fluctuating tumor 
in the hypogastric region, reaching almost as high as the umbilicus. 
This physical examination and the history of four months amenor- 
rhoea made the diagnosis of retroversion of the gravid uterus per- 
fectly plain. What concerns us here, however, is that the bladder 
contained only about twenty-three ounces of urine, a less amount 
than in the previous instance. 

Case HI. — Along with Prof. Simpson I saw at the Maternity 
Hospital a patient with rigidity of os uteri, supposed to necessitate 
early application of the long forceps ; supra-pubic inspection and 
palpation revealed a fluctuating tumor bluntly triangular in shape, 
with the apex down. Exact measurements showed that vertically it 
extended four inches, and transversely for about the same distance. 
The catheter passed deeply up, and drew off only two ounces and a 
half of clear urine, and some time afterward the same apparent dis- 
tention occurred, when three ounces and a half were removed. Af- 
ter the bladder was thus emptied, the furrow between cervix and 
uterus could be felt two fingers' breadth above the symphysis j^ubis. 
These three cases are typical instances, and evidently call for expla- 
nation. 

In the first case narrated the bladder was simply distended. It 
had pushed the intestines up, tilted the uterus back, but its posterior 
wall was still in its normal position. The peritonaeum was still on 
the summit of the bladder, but, of course, was stripped to a certain 
extent from the lower part of the posterior aspect of the anterior 
abdominal wall. Thus the bladder, though its summit was only at 
the level of the brim, was considerably distended. Now, in the 



772 DISEASES OF WOMEN. 

retroversion of tlie gravid uterus, the bladder was certainly distended, 
supra- pubic palpation, however, misled as to the amount of disten- 
tion, and for the following reason : The cervix uteri was tilted 
high up behind the symphysis pubis, and consequently the blad- 
der, to whose posterior angle the cervix is attached, was swung 
up, as it were, into the abdominal cavity, a movement permitted by 
the anatomical relations behind the pubis. The peritoneal relations 
were the same as in Case I. In the third case, the bladder was, of 
course, drawn up, as I have already shown,* and its relations were as 
follows : In front it touched the anterior abdominal wail ; behind, 
the cliild's head, the cervix, of course, intervening. In this way the 
anterior and posterior vesical walls were in contact, and thus a film 
of urine, as it were, gave the appearance of distention. As I have 
before pointed out, the peritonseum is stripped off the bladder 
more or less.f 

The conclusions advanced are : 1. The retro-pubic anatomical 
attachments of the bladder admit of its distention and passage up- 
ward. 2. Supra-pubic palpation gives no sure indication of the 
amount of urinary distention. 3. When the summit of the blad- 
der is above the pubis, it may be {a\ a pure distention (Case I) ; (b\ 
distention plus a tilting up (Case II) ; (c), drawing up of the blad- 
der, with almost no distention (Case III). 

The reason why gynecologists use a long gum-elastic catheter is 
very evident. I have already described the empty bladder in the non- 
parturient female as forming a Y-shaped figure on vertical section. 
During parturition, however, the urethra is elongated, and forms 
with the bladder, on vertical section, a continuous tube, if Only 
that part of the bladder above the pubis is available for the recep- 
tion of urine, so that in this way the path for the catheter to travel 
is increased. In Braune's section of a woman in labor, the distance 
for the catheter to travel is about fom- and a half inches, more than 
twice what it is normally. 

In the last place, the distended female adult bladder is quite 
comparable in its anatomical relations to the distended fetal one. 
This may point to the explanation that the ultimate changes which 
convert the urinary bladder from an abdominal organ into a pelvic 
one is chiefly in the bony pelvis itself. 

Retrocession and Forward Transposition of the Uterus. — The vari- 
ous forms of displacement of the bladder described thus far, are usu- 

* "Edinburgh Medical Journal," April, 18'79. 

f "Edinburgh Medical Journal," September, 1879, "Edinburgh Obstetrical Transac- 
tions " (Part II, p. 142). % See " Die Lage des Foetus," Braune, Tab, C. 



NOX-INFLAMMATORY DISEASES OF THE BLADDER. 773 



allv associated with uterine dislocations, and are familiar to those 
who have given attention to gynecology. There remains to be no- 
ticed two forms of displacement of the nterus not generally described 
by authors, but which markedly disturb the functions of the blad- 
der, viz., retrocession diudi forward transposition. In the first form, 
the uterus, without any change in the relation of its axis to the 
plane of the superior pelvic strait, is found to rest far back in the 
pelvis, and is fixed there. In the second form, the reverse of this 
exists, the uterus resting just behind the pubes. Figs. 240 and 241, 
wiU show these conditions. 

The best example of retrocession I have ever seen was in a pa- 
tient who had had a severe pelvic peritonitis sometime before she came 
to me. The uterus was firmly fixed in the posterior portion of the 
pelvis, and the bladder was drawn backward, and was exceedingly 
irritable. This condition caused her great trouble, as she could never 




Fig. 238. — Forward transposition of the uterus. The bladder will be seen somewhat flat- 
tened against the pubes, and the urethra pushed out of its axis. 

completely empty the organ, except when the catheter was used. 
Owing to the fixation of these organs in their malposition, it was 
impossible to relieve her from the frequent and difficult urination, 
and she remained a great sufferer, until she died of phthisis pul- 
monalis. 



774 DISEASES OF WOMEN. 

To illustrate the forward transposition, I may mention a case 
that came under my notice several years after she had had an intra- 
peritoneal pelvic haematocele. Her physician told me that she had 




Fig. 239. — Retrocession of the uterus. The vagina is here found lengthened, and the 
bladder and urethra pulled upward and backward, a, adhesions, b, bladder. 

severe inflammation following the internal haemorrhage, and nearly 
lost her Hfe therefrom. She was confined to her bed for many 
months, and after recovery she suffered from frequent urination. 
Night and day she was obliged to pass water every two hours, and 
if she went longer than that, she had pain which was not relieved 
till some time after emptying the bladder. The uterus was situated 
at its proper elevation, and was just behind the pubes. The bladder 
was compressed from before backward, and (as the uterus was 
firmly fixed in its forward position) of course it could never be 
fully distended. There was no disease of the bladder, so far as could 
be ascertained from an examination of the urine, or of the organ 
itself. No treatment that was employed gave anything more than 
temporary relief. 

(/) Inversion of the Bladder. — This affection stands next in rarity 
of occurrence to complete prolapsus of the bladder through a fissure 
in the abdominal walls. It is sometimes denominated as extrover- 
sion of the bladder through the urethra. 



NON-INFLAMMATORY DISEASES OF THE BLADDER. 775 

By some authors it is supposed to be a simple protrusion of tlie 
mucous coat of the bladder through the urethra, but by others to be 
a prolapse of the whole organ. In support of the latter belief is the 
fact that after death Joubert, Rutlj and Leoret found a sinking in 
or partial inversion of the whole organ. Moreover, Meckel claims to 
have found under the labia minora, and protruding from the meatus 
a mass of tissue that on careful examination proved to consist of all 
the elements of the several coats of the bladder. 

Burns thinks it much easier for a prolapse of the whole organ to 
take place than a separation and prolapse of the mucous membrane 
alone. Streubel, after a careful review of the literature of the sub- 
ject, was able to find but one case in which the mucous membrane 
was alone prolapsed. As the posterior vesical wall in the empty 
organ Hes over the vesical opening of the urethra, it is easy to com- 
prehend how this dislocation might occur from sudden straining 
efforts, pressure of the overloaded colon, or pressure of a heavy 
uterus. Vesical tumors with long pedicles coming out through the 
urethra, by weight or from traction, might produce this result. 
The process of extroversion is generally slow. De Haen, quoted by 
Streubel, gives a case, however, where from force, the bladder, rec- 
tum, and vagina were all prolapsed together. It will be understood 
that in order to have the bladder turned inside out, the urethra must 
be abnormally dilated. 

It may occur at any age. Weinlecher saw it in a child but nine 
months old ; OKver, in one of sixteen months ; Crobs, in one from 
two to three years ; Streubel, in a girl fourteen years old ; and Thom- 
son and Percy, in women aged respectively forty and fifty-two. 

Symptomatology. — The patients, even before the tumor appears, 
feel strong pressure in the organ on urination, and may have stop- 
pages in the stream and retention. After a time these symptoms 
become aggravated, a small red tumor appears at the meatus, and 
with each urination enlarges. With the appearance of the tumor 
comes pain. In some cases, when the desire to urinate is felt, severe 
contraction of the bladder takes place, but no urine flows. Then 
suddenly the little tumor disappears inside, and the urine flows freely. 
With each appearance of the tumor there is considerable constitu- 
tional disturbance, and after a time the appetite is lost, and the suf- 
ferers emaciate rapidly. From continual traction on the ureters, 
they may become inflamed, and also the kidneys, and uremia super- 
vene. Blood is sometimes passed with the urine. Cystitis may 
occur, which increases the suffering and danger. The mucous mem- 
brane may become hypertrophied, congested, and even edematous. 



776 DISEASES OF WOMEN. 

The constitutional symptoms bear no relation to the amount of tissue 
extruded or the area of mucous surface exposed. 

Diagnosis. — Fortunately, this affection is a rare one, for the diag- 
nosis is hy no means easy. The surface of the tumor should be ex- 
amined, and the nature of its epithelium carefully noted. Eeduc- 
tion should be tried, and, if successful, examination should be made 
by the sound in the bladder, and the finger in vagina or rectum (the 
latter in infants), to ascertain, if possible, whether there be any thick- 
ening of the membrane or a tumor in the viscus. If on the surface 
of the protrusion the orifices of the ureters can be found, the diag- 
nosis is at once settled. Polypoid projections of the mucous mem- 
brane must be differentiated from protrusion of the viscus itself. 
Such cases are described by Baillie and Patron. 

From prolapsus of the urethral mucous membrane, which I shall 
hereafter describe, this condition is to be differentiated by the absence 
in the latter of the ureteric openings and the position of the meatus 
urinarius. In urethral prolapse the orifice is situated either centrally 
or superiorly, while in vesical protrusion the meatus surrounds the 
pedicle. In the latter there is a large strong pedicle ; in the fonner 
none. 

Treatment. — The treatment naturally divides itself into prophy- 
lactic and curative. To prevent partial extroversion from becoming 
complete, narcotics and demulcents should be given by the mouth 
and rectum, or injected into the bladder. Opium, hyoscyamus, and 
belladonna may all be tried. Local cauterization and washing out 
with tonic injections might prove serviceable. These preventive 
means are usually suflicient, provided the urine is normal and the 
mucous membrane healthy. If either of these abnormalities exist, 
they should be corrected. 

If the tumor is down, its reposition should be attempted. Gentle 
manipulation with the finger should be tried, and, if the mass can 
not be put back in this way, a well-oiled blunt catheter should be 
used, making pressure with it in the direction of the axis of the 
urethra. If this is very painful, and there are spasmodic contrac- 
tions of the abdominal muscles, which prevent replacement, the 
patient should be etherized, and success may then follow. She should 
be on her back, or in the Sims's position. 

To prevent prolapse after reduction, the catheter may remain m 
situ for a time, or the colpeurynter or tampon may be used. Schatz's 
pessary for urinary incontinence may be employed advantageously, 
as its use tends to contract the vesical neck. Astringent injections 
may be used. No operative procedure is required. 



CHAPTER XLIII. 

NON-LNTLAMMATORY DISEASES OF THE BLADDER (cONTINUEd). 

FOREIGN BODIES IN THE BLADDER. 

FoEEiGi^ bodies found in the female bladder are divided into three 
classes by Winckel, as follows : 

{a) Those that come from the body, entering the bladder by per- 
foration. 

(b) Those which have their origin in the bladder. 

{c) Those that are introduced from without through the urethra. 
I will adopt this classification, believing it to be the most natural 
and convenient. 

{a) First then, as to those that come from the body, entering the 
bladder by perforation. 

That cysts ever originate in the bladder is doubted by some and 
denied by others. In most cases where they are found in this organ 
they can be traced to dermoid cysts of the ovary which have found 
their way into it, thus accounting for the presence of hair, teeth, and 
other tissues in this viscQS. These things are never found there 
unless such a cyst has opened into the bladder. The contents of 
these dermoid cysts may become nuclei for calculi, and lead to seri- 
ous trouble. 

I think there can be no doubt but that some of the cysts found 
in the bladder have their origin there. Mucous follicles certainly 
do exist in the bladder, and are liable to have their orifices blocked 
or occluded, and by secretion behind the point of obstruction grad- 
ually form cysts. Interesting cases, where the cysts evidently had 
their origin in the bladder itself, are related by Paget, Liston, and 
Campa. It is, however, undoubtedly the fact that most cysts of the 
bladder have their origin outside that organ. 

Cysts of the ureters and urachus may open into the bladder. 
Hydatid cysts have been found, but are less frequently seen in this 
51 



Y78 DISEASES OF WOMEK 

country than in almost any other. Iceland is especially cursed with 
them, about one sixth of the population suffering from them in some 
part of the body. They may appear in the urine, white and pearly 
in appearance, or be of a dirty yellowish color, from prolonged soak- 
ing in foul urine. 

Treatment. — These cysts, or their contents, if giving rise to any 
trouble, should be treated in the same manner as the neoplasms, of 
which I shall speak later. 

In the treatment of hydatid cysts, iodide of potassium has been 
especially recommended. Having never had occasion to use it for 
this purpose, I can say very little for or against it. 

Other Foreign Bodies. — Yarious parts of the foetus have found 
their way into the bladder by ulceration during extra-uterine preg- 
nancy, and pieces of ulcerated intestine, masses of feces, fecal con- 
cretions, and biliary concretions, are some. of the curious things that 
have been found in tliis viscus. In gun-shot and other injuries to 
the pelvic bones, osseous splinters have found their way into the 
viscus, and been evacuated through the urethra, or have passed into 
the vagina or rectum by ulceration, or have remained, forming nuclei 
for calculi. 

Yarious parasites may penetrate the walls from the immediate 
tissue or neighboring organs, or come down from the kidneys, such 
as the echinococci, already spoken of, the distoma haematobium or 
the filaria sanguinis hominis. Joints of tape- worm, the ascaris lum- 
bricoides, and the thread- or seat-worms have also been found here, 
entering either through a fistulous opening, existing between the 
bladder and intestine, or through the urethra. 

In acute destructive change in the kidneys (pyonephrosis and 
abscess), pus and pieces of renal tissue are not unfrequently carried 
down into the bladder, and may, by frequent incrustation with 
the urinary salts, result in the formation of calculi. Of themselves, 
they give rise to very little, if any, irritation, and are consequently 
of no importance save in relation to the destructive changes going 
on in the kidney, of which they tell the story. If such discharges 
from the kidneys continue for a long time, they cause cystitis. 

Renal calculi may become dislodged, and be swept down into the 
bladder, there to enlarge by further incrustations, or pass out through 
the urethra. 

Symptomatology. — The symptoms of the various foreign bodies 
in the bladder differ only in degree. They are at first those of irri- 
tation ; later those of acute or subacute inflammation. Bodies round, 
smooth, and soft, are, of course, less irritant than those that are rough 



NON-INFLAMMATORY DISEASES OF THE BLADDER. 779 

or sharp. Cysts, therefore, bits of flesh, and their like, as a rule, 
give rise to no very severe symptoms, while spKnters of bone and 
calculi occasion much more severe manifestations. Pain and tenes- 
mus will vary with the character of the offending body. If the 
mucous surface be abraded or torn, hsematuria will result ; and, if 
the foreign body remains in the organ, and continues to irritate it, 
cystitis will follow, and the patient suffer increased agony. 

The extension of the inflammation upward, and involvement of 
one or both kidneys, will give rise to pain in the back, hectic fever, 
partial or total suppression of urine, and consequent ursemic symp- 
toms, ending fatally. 

The urine shows the various appearances of cystitis, of which 
sufficient has already been said, and also the signs of renal involve- 
ment, if such be present. 

Treatment. — Any foreign body, when known to be present in 
the bladder, should be removed at as early a date as possible. In 
the adult female this may be readily accomplished by dilatation of 
the urethra, or, if the body be too large, by Simon's vesico-vaginal 
section. 

In cases of fistulous communication between the bladder and in- 
testine or other organ, an attempt should be made, in the manner 
already spoken of, to close the opening. 

Echinococci and other parasites should be treated with the vari- 
ous remedies recommended for their destruction elsewhere, always, 
however, removing the offending body from the bladder first, and 
trying to prevent further invasion by proper medication. 

If cystitis be present, this will be attended to in the prescribed 
way. 

Hydatids in the Bladder. — Dr. J. A. McKennion, of Selma, Ala- 
bama, reported a case in the " American Medical Weekly," Louisville, 
Kentucky, in 1874 or 1875. The purport of this report, according 
to my recollection, is that it was a case which, when first seen, had 
every indication of cystitis, with great thickening of the walls of the 
bladder. Frequent micturition caused the patient to exclude her- 
self from society for two years before a correct diagnosis of the case 
was formed. She was becoming prostrated from constant dysuria, 
and, in order to give her quietude, Dr. McKennion says, I attempted 
to introduce a Sims's catheter, to be retained during the night ; but, 
meeting with an obstruction in the bladder, and, by manipulation 
with catheter, finding that she was insensible as to the point of the 
instrument, I concluded that a hydatid formation was present, and 
designed at once to have it expelled if possible. 



780 DISEASES OF WOMEN. 

I would saj here one of the strongest arguments in my own mind 
at the time of hydatid formation was, when force was used to push 
up the instrument farther, a small amount of fluid escaped, and no 
blood. I injected into the bladder two drachms of liq. sodee chlor. 
(French preparation). In about an hour violent spasms of the blad- 
der occurred, the urethra dilated, and there was expelled into the 
vessel about a pint of hydatid. The shape and attachment of these 
resembled the cactus ; the sacs were transparent and well defined. 
There was but slight haemorrhage. This I attributed to the forcible 
distention of the urethra. ' It is now over five years since their ex- 
pulsion, and up to this day my patient has had no more inconven- 
ience with her bladder. Fortunately, my case was a female, and 
she is well ; this might not have been if it had been one of our own 
sex. — New York Medical Record^ November W, 1880, p. 688. 

(b) Bodies having their Origin in the Bladder Itsel£ — Under this 
head come calculi, which may be of various kinds, as uric acid, triple 
and amorphous phosphates, oxalate of lime, and cystine. The latter 
are quite rare. Again, the calculi may consist of more than one of 
these ingredients. 

Time will not allow me to enter into the extensive field embrac- 
ing the etiology and treatment of stone. For a comprehensive study 
of this matter, I must refer the reader to any one of the many excel- 
lent works on that subject. 

Calculus. — I shall only speak of one or two points in connection 
with calculus that are of especial interest in the study of disease of 
the female bladder. Stone in the bladder is not so common among 
women as among men. This, I presume, is OTvdng to the large and 
easily dilatable urethra of the female, which permits small renal cal- 
culi to pass out ; calculi of the same size in the male being retained 
in the bladder, and serving as nuclei for larger ones. 

8ymjptomatology . — The symptoms are simply those of a foreign 
body in the bladder, varying with the size, shape, and number of 
the stones, and also their roughness of surface. Frequent urina- 
tions, tenesmus, pain before, during, and after urination, some- 
times incontinence, and always more or less cystitis. Hgematuria is 
not at all infrequent, and the urine presents all the characters of 
bladder inflammation, as shown by the presence of pus, epithelium, 
and, sooner, or later, numerous crystals of the triple and amorphous 
phosphates. 

The constitution suffers from the constant pain and frequent 
urination, and the patient gives all the symptoms of a severe cystitis. 

Diagnosis. — This is comparatively easy in the female bladder. 



NOX-INFLAMMATORY DISEASES OF THE BLADDER. 781 

for between the judicious use of the sound, conjoined manipulation, 
and the bladder speculum, a stone can hardly escape detection un- 
less it be verj small or completely encysted. 

Prognosis. — The prognosis in vesical calculus in women is good, 
provided the kidneys be not seriously disordered. The cystitis usu- 
ally disappears soon after removal of the foreign body, under 
proper treatment ; and even if renal disease exist, it may also sub- 
side. 

Causation, — The causes of stone in the bladder are about the 
same in both sexes, and so I need not dwell long on this part of the 
subject. I may call attention to one cause of the formation of 
stone in the bladder of the female. In cystocele, a mass of mucus 
or shreds of membrane and triple and amorphous phosphates gradu- 
ally collect in this abnormal pouch, and form a nucleus for stone. 
It is a curious fact, too, that women are particularly liable to have 
stone after the operation for closure of vesico-vaginal fistula. There 
has been considerable discussion as to whether calculi, discovered 
soon after this operation, existed undiscovered in the bladder before 
the operation, or were formed rapidly after it. Henry F. Camp- 
bell, M. D., of Virginia, relates one case in favor of the former 
view, and Dr. T. A. Emmet several in favor of the latter. 

The belief has been advanced that irritation in the bladder mod- 
ifies the urinary secretion sufiiciently to cause deposit of the urin- 
ary salts, and thus account for the formation of stone after the 
operation for fistula. It is claimed that reflex nerve action is ex- 
cited by the operation, the inflammatory action about the edges of 
the wound, or by cystitis already existing. 

This idea that the reflex nerve influence modifies the urinary se- 
cretion sufiiciently to result in the formation of stone in these cases, 
is, I think, hardly tenable; for in hundreds of cases of cystitis, 
where the reflex action does un doubt edl}^ exist, no stone is formed. 
Then, too, the secretion is as a rule rendered more watery, instead 
of concentrated, a condition in which precipitation of tlie urinary 
salts would be very unlikely to take place. 

A middle position on this question seems to me to be the most 
rational, and stones found after operations for closing fistula might 
be due to any one of three causes : 

{a) Calculus already existing in the bladder, escaping detection by 
being pocketed, or so small as to lie beneath a mucous fold, and 
rapidly increasing in size after operation, due to the retention of the 
salts of the urine (deposited by decomposition), that formerly es- 
caped by means of the fistula. 



782 DISEASES OF WOMEN". 

(h) Calculi, small or large, existing in the kidneys or renal pelves, 
and washed down after the operation by the increased flow of limpid 
urine : these, too, increasing in size by incrustation. 

(c) Calculi, the formation of which commences directly after 
closure of the wound, due partly to retained products of decomposi- 
tion, possibly to modified secretion, or to small nuclei swept down 
from the kidney, or, what is much more likely, to nuclei consisting 
of pieces of mucous shreds, blood-clots, or possibly incrustations on 
one or more of the sutures which may be exposed in the bladder. 

I am quite sure that the formation of calculi after closing a ves- 
ico-vaginal fistula is favored by the presence of the catheter in the 
bladder during the healing process. The drainage is imperfect and 
if the bladder is not frequently washed there is every facility for the 
deposit of urinary salts and the formation of stone. I am the more 
persuaded that this explanation is correct from the fact that, since I 
have permitted my patients to empty the bladder in the natural way 
after the operation, I have not had a case of stone following this 
operation. 

Treatment. — The female bladder presents an inviting field for 
experiments on the treatment of stone by solvents ; but as the opera- 
tion here is so easy and its results so good, it seems hardly justifiable 
to recommend any other method of treatment. In patients, how- 
ever, who object to the operation, it may be tried. For a full and 
interesting account of experiments and statistics on the solvent 
method, I refer to Mr. Roberts's most excellent work on " Urinary 
and Kenal Diseases." 

The stone being found and its size determined, it may either be 
removed by cystotomy or crushed. If the stone be small and soft, 
it may be advisable to crush it, washing out the fragments through 
the open speculum in the moderately dilated urethra, thus saving 
the urethral mucous membrane from laceration by the sharp frag- 
ments; or better still the debris may be removed by Bigelow's 
method. 

If much cystitis be present, however, or if the stone be large, it 
is advisable to perform vaginal cystotomy. In this way a stone of 
large size may be removed from any part of the bladder, and an 
opening for drainage is left to act beneficially on the inflamed organ 
by giving vent to the urine and its sediment. The bladder should 
be carefully washed out daily with a warm solution of salicylic acid 
(1 to 600 or 1 to 400). If drainage is desired, care must be taken to 
keep the incision open, for it closes very readily. 

I have spoken several times already as to the method of per 



NON"-INrLAMMATORY DISEASES OF THE BLADDER. ^83 

forming vaginal cystotomy. Emmet dwells especially and justly on 
the necessity of fixing the vesico-vaginal wall tirmly with a tenacu- 
lum before commencing the incision, which may be made with 
either a knife or scissors. A calculus in the bladder, if interfering 
with labor, or if liable to be caught between the child's head and 
the pubes, should, if possible, be pushed up out of the way. This is 
seldom successful, and as much damage may be done the bladder by 
the crushing of its walls, it is best to puncture and remove the stone 
at once in case there is time during the labor and the attendant is 
prepared to operate. Should it be impossible to operate before 
labor is completed, it should be done as soon afterward as practi- 
cable. It should be borne in mind that the vascularity is greater in 
the puerperal state and hence every preparation should be made to 
arrest hsemorrhage. 

ILLUSTRATIVE CASES. 

Foreign Bodies in the Bladder.— By L. H. Dunning, M. D. ; read 
before the " Indiana State Medical Society " : 

Case I. — Mrs. A., aged thirty-eight, married, a lady of culture 
and refinement, was delivered, four years previously, of a hydro- 
cephaloid child. The delivery was instrumental. Whether from 
long pressure of an abnormally large head, or from maladroit use 
of instruments, I know not, a vesico-uterine or vaginal fistula re- 
sulted. The precise location of the original opening of the vaginal 
or uterine extremity of the fistula I am unable to state, as two 
operations had been done for its closure, both of which were un- 
successful. The last operation was done in June, 1883, and in 
the foUoAving December I was consulted in consequence of intense 
pain and burning in the region of the bladder, and pain at the 
close of the act of urinating. The patient stated she had, a few 
weeks previously, passed a small stone by the urethra, and now 
thought there was another and larger one present. An examination 
with the sound confirmed her diagnosis. I proceeded to remove 
the stone, assisted by Dr. S. L. Kilmer. The urethra was dilated 
with a three-bladed dilator, the stone crushed with a Thompson's 
litho trite, and removed with Bigelow's evacuating apparatus. We 
were both confident all the stone was removed. The patient made 
a good recovery, but was not entirely relieved of the bladder symp- 
toms. In March, 18S4, I was again called to remove a stone, which 
the patient stated she had felt with the large end of a shawl-pin in- 
troduced into the bladder through the urethra. This time, assisted 
by Dr. M. L. Morse, a large quantity of stone was removed in the 
same manner as at the first operation. The lithotrite was introduced 



784: DISEASES OF WOMEN". 

three times, and, the last time it was withdrawn, we found within 
the grasp of its closed blades a silver-wire suture, with the loop cut, 
but the twist intact. The whole was coated with a phosphate-of-lime 
deposit. "We now felt confident we had secured the foreign body 
around which the calculus had collected. The patient stated to us 
that she had been aware ever since the last operation for fistula that 
there was a wire left behind, and that she had once visited the sur- 
geon to have it removed, but it could not be found. There are 
many other points of Acceding interest connected with this case, 
but they are not pertinent to this subject, hence will be omitted. 
There was a band of dense cicatricial tissue extending transversely 
across the fundus of the bladder. Posterior to this band was a 
pocket, in the bottom of which was the vesical extremity of the fist- 
ula. In this pocket lodged the stone, and was evidently made sta- 
tionary by the suture, which remained partly imbedded in the tissues. 
That the wire rendered the stone stationary finds support in the fact 
that, July 18th, four months after the wire was removed, a fourth 
large calculus had formed in the bladder, and was quite movable. 
This last calculus was readily crushed, and voluntarily expelled from 
the bladder along with water freely injected into the organ. Since 
this fourth stone was removed, there have been no signs or symp- 
toms of a calculus in the bladder. 

Case IT. — Mr. B., a laborer, aged fifty-seven years, was brought 
to me, by Dr. Kettring, September 19th, of last year, for the re- 
moval of a foreign body from the bladder. The patient stated that, 
about the middle of August, he passed a cigarette-holder into the 
orifice of the urethra ; that it slipped away from him, and passed 
down into the urethra, and, in his efforts to remove it, pushed it 
into the bladder. Being a mechanic, he had invented an instrument 
with which he attempted to remove the body, without success. I 
sounded the bladder, and found the holder lying obliquely across 
the organ. I judged it to be about two and one half inches long, 
and as thick as a small lead-pencil. A 'No. 18|- sound dropped readily 
into the bladder, and, since the urethra was of so large a caliber, and 
the patient had frequently passed his instrument along its track, I 
concluded to attempt its removal without further dilatation. A 
Thompson's lithotrite was introduced, and the body seized ; but I 
was made conscious that the instrument did not grasp it at the end, 
so I withdrew the lithotrite and introduced a sound, and endeavored 
to bring the long diameter of the holder in line with the urethra. 
Now, with but little difiiculty, the end was grasped by the blades 
of the lithotrite, and I proceeded to withdraw the whole. It soon 



NON"-INFLAMMATORY DISEASES OF THE BLADDER. 785 

became evident that we had not rightly estimated the size of the 
holder, for, although it, together with the instrument, entered the 
prostatic portion of the urethra, we had considerable difficulty in 
making it advance through the membranous portion. However, 
avoiding much force, but keeping steadily at work, with the aid of 
Dr. Kettring, I succeeded in withdrawing it to within one inch and 
a half of the orifice of the urethra. Further than this we could 
not advance ; so the urethra was incised posteriorly down to the end 
of the holder, and, by applying pressure from behind, made to enter 
the incision, and was finally entirely withdrawn. We were surprised 
to see the size of the holder and its breadth when in the grasp of the 
lithotrite, thirty-five millimetres. There was a moderate amount of 
haemorrhage from the urethra or bladder; probably from the mem- 
branous portion of the urethra, since that is the most constricted por- 
tion of the canal. The bladder was washed out with tepid water, 
and the patient taken to his home in a closed carriage, the operation 
having been done at my office on account of the patient's refusing to 
have it done at home for fear of exposure. Soon after reaching 
home, the patient had a chill, followed by fever. In the next 
twenty-four hours he had three chills, each time followed by in- 
creased fever, the temperature ranging from 102° to 10i° F. The 
urine passed was freely mixed with a considerable qnantity of mucu5 
and a little blood. 

20th, 1.30 p. M. — Patient seen by Dr. Kettring and myself. Had 
a temperature of 106°. He voided urine in our presence ; it was 
quite bloody, and, upon close examination, was found to contain a 
wedge-shaped piece of mucous membrane twelve millimetres long, 
four millimetres broad, and about two millimetres thick. This was 
not examined with the glass, but was supposed to be from the mem- 
branous portion of the urethra, since at that point there was the most 
resistance. There were also voided at this time several small grains 
of gravel, some as large as wheat-grains Patient complained of con- 
siderable pain. Bladder was w^ashed out with warm carbolized water. 
Twenty grains of quinia sul. were given ; one grain opium and ten 
grains of acetate of potash every four to six hours, and a milk-diet 
ordered. Further than this, I will not attempt to minutely detail the 
history of the case, but will simply outline it. In the next twenty- 
four hours the patient had four chills. The temperature ranged from 
101° to 104°, and the pulse from 108 to 120 per minute.^ Patient 
perspired profusely, and was at times delirious ; great nervousness : 
prognosis was regarded unfavorable. Whisky, in 3 jss doses, every 
hour, when the temperature mounted high, was added to the treat- 



786 DISEASES OF WOMEN". 

ment. Dr. Kettring washed out the bladder t\dce every day, "Qsing 
for this purpose a soft-rubber catheter and a rubber bag. We de- 
bated the advisability of this procedure, but found that, by this 
means, we removed a considerable quantity of turbid urine, small 
clots of blood, and occasionally small grains of gravel ; and further, 
the cleansing of the bladder seemed to afford the patient relief ; so 
we decided to persist in it as long as its use was indicated. 

22d. — Patient slightlv delirious ; pulse, 112 ; temperature, 101° ; 
slept moderately well last night ; has had no chill since 9 p. m. yes- 
terday. Dr. Kettring found morphine, gr. one sixth, ar. spts. ammo., 
3 jss, very efficient in relieving or aborting the chills. At noon 
to-day patient seemed much better ; at 9 p. m. temperature had fallen 
to 100°, and pulse to 90 ; but the urine had accumulated in the blad- 
der, and had to be removed by catheterization. 

23d, 7.30 A. M. — Patient rational ; has slept well during the 
night, and voided urine frequently ; pulse is TO, and temperature 
normal ; the nervous symptoms have nearly disappeared ; had symp- 
toms of a chill last night, which quickly disappeared under the effects 
of the morphine and ar. spts. of ammo., with the addition of ten 
drops of chloroform. 

From this time forward the recovery was uninterrupted. In one 
week the patient was able to sit up. A few days later he was walk- 
ing about the streets, and in two weeks after the operation resumed 
work. 

Thus happily terminated a case that at one time was exceedingly 
alarming, in consequence of the intense urethral fever that devel- 
oped. It would undoubtedly have proved fatal had it not been for 
the skill and unremitting attention bestowed upon the case by Dr. 
Kettring. 

Stone in the Bladder ; Lithotrity by a Single Operation. (N. A. 
Powell, M. D., Edgar, Ontario.) — S. P., aged now fire years, first 
presented symptoms of trouble referable to the urinary organs in 
October, 1S76. Pain, partial incontinence, and the passage of 
blood and mucus continued from this time, and in January, 1878, a 
bit of '^ gravel " the size of a split pea came away. During the 
following spring the desire for urination became almost constant, 
and vesical tenesmus was marked. On June 12th, my friend. Dr. 
Blackstock, of Hillsdale, was called to see her, and on the 13th, 
under an ansesthetic, he examined, and found a calculus at the neck 
of the bladder. 

An operation for its removal was advised, and pending this, 
anodynes were freely given. On July 9th, the writer, in consultar 



NON-INFLAMMATORY DISEASES OF THE BLADDER. 787 

tion, saw tlie case for the first and only time. The child was said 
to be failing very fast ; she was much emaciated ; was suffering 
severely, and seemed to gain a respite from her pain only when 
violently rocked while in the knee-chest position in a cradle. Pulse 
140, temperature 102^° F. Chloroform, replaced later by ether, was 
given, and a stone found jammed into the upper part of the urethra. 
This was displaced upward, caught in the blades of a smaller Weiss 
and Thompson lithotrite, and crushed. The scale showed ^re eighths 
of an inch separation of the blades. Further comminution of the 
fragments was effected by means of long polypus forceps. Evacua- 
tion was accomplished by the same, aided by the frequent injection 
and aspiration of warm water through a large-sized Eustachian 
catheter, to which a strong rubber bulb had been attached. This 
last was the best substitute at hand for Bigelow's or Clover's appa- 
ratus. The vagina was too small to admit a finger without undue 
stretching, but water could be retained in the bladder by pressure 
upon the urethra. 

The first calculus being removed, suprapubic pressure brought 
two other and smaller ones within reach, and these were treated as 
the first had been. The distance between the outer surfaces of the 
blades of the forceps used w^hen grasping the largest fragment re- 
moved was three tenths of an inch; this, then, was the limit of 
urethral dilatation. The lithotrite was used for crushing five times, 
the forceps twenty or thirty times. The time occupied was one 
hour and a quarter. The bladder being washed and aspirated till, 
as nearly as possible, freed of its solid contents, the child was put to 
bed with hot applications over the pubes and to the extremities, and 
a full anodyne was given. The detritus collected at the time of 
operation weighed 241 grains ; subsequently seven grains more 
were obtained from the strained urine. 

For the history of the case after this, I am indebted to notes 
kindly sent me by Dr. Blackstock or his assistant Mr. Gould, who, 
with my students Messrs. Shepherd and Bremmer, gave assistance 
during the operation. " Partial control of the urine returned on the 
day following the lithotrity, and complete control, except during 
the night, after three days. The desire to void urine occurred 
about every hour for several days, and at the end of a week, about 
every third hour. Slight haematuria was noticed for two days.*" 
Under date August 27th, I hear that " the child's general health is 
good. She is gaining in flesh, and has no symptoms of her former 
trouble." 

The above case would a year ago, hardly have merited transcrip- 



788 DISEASES OF WOMEN. 

tion from the case-book of a country physician to the pages of a 
medical journal. But since the appearance of Dr. Bigelow's paper 
on litholapaxy * the whole subject of the tolerance of the urinary 
bladder for prolonged instrumentation has come up for reconsid- 
eration, and this is offered in evidence. 

From Civiale down, all lithotritists, so far as the writer's knowl- 
edge extends, have held that the visits of a lithotrite to the interior 
of a bladder must be strictly limited in point of time. Though ex- 
perts may, at times, have given themselves more latitude, they have 
always taught others not to exceed five minutes for any one crush- 
ing. Of late years, also, the tendency has been to confine the opera- 
tion within narrow and yet more narrow limits, treating by it only 
such moderate sized stones as could be got rid of in from two to 
four sittings. It remained for the Harvard professor to demonstrate 
that the calculus-containing bladder of an etherized man might be 
manipulated for one, two, or more hours, and yet not resent it by 
cystitis or subsequent atony ; provided that no sharp fragments were 
left in it to do outrage to its lining membrane. Although the case 
just given occurred in a female child instead of in an adult male, it 
seems to support Dr. Bigelow's conclusions as to vesical tolerance. 
Surely the delicate tissue of a child's bladder is ill adapted for pro- 
longed contact with instruments, while the proportion of the organ 
covered by peritonaeum in the child being greater than in the adult, 
there would seem to be a greater danger of serous inflammation. 
Yet, here all irritation promptly subsided when the irritant was re- 
moved, although its removal took one hour and a quarter. May 
we not expect like results when even large stones are crushed in the 
male bladder, and evacuated by the new method ? Statistics so far 
— seventeen cases, sixteen successful — seem to point that way. 

It may be asked why the urethra was not more widely dilated 
in this case ? My answer is that too large a proportion of those thus 
treated have been made dribblers for life by it. The case with 
which stretching may be accomplished, and the free access which it 
gives to the bladder, will strongly tempt a surgeon who does not 
look beyond the operation he has to do at the future life of his 
patient. Prof. Simon, of Heidelberg, made f many accurate meas- 
urements to determine the extent to which the adult female urethra 
may be dilated without the risk of incontinence. His limit is in 
width, eight tenths of an inch ; in circumference, 6*3 cen., (=2*4: 
inches). This would allow a finger to pass, but not a finger plus a 

^ " American Journal of Medical Sciences," January, 1878. 
f Translation in " New Fork Medical Journal," October, 1875. 



NON-INFLAMMATORY DISEASES OF THE BLADDER. 789 

pair of forceps. Mr. J. R. Lane thinks no stone larger than an 
acorn should be removed entire through the urethra of an adult 
female, and none larger than a bean through that of a child. Dr. 
Hnnter McGuire, of Richmond, Ya., states that many cases of so- 
called successful operations by dilatation and extraction have, to his 
personal knowledge, been followed by incontinence. Rapid dilata- 
tion, however, seems to be less dangerous than slow. In proof of 
this, I may, in conclusion, mention that I have knowledge of the 
case of a girl, aged twelve years, into whose bladder a pair of 
sequestrum forceps was pushed, a calculus seized and extracted 
vi et armis^ dilating and lacerating the urethra as it came. The 
stone was as large as a pigeon's Qgg. Absolute incontinence existed 
for twelve days, but was followed by recovery. 

Stone sacculated in the Bladder of a Female. (By Charles Will- 
iams, F. R. C. S., Ed., Surgeon to the Norfolk and Norwich Hos- 
pital). — Cases in which a vesical calculus is impacted in a cyst situated 
in the walls of the bladder are so extremely rare that I consider it 
a duty to record this very interesting example : 

A fine, healthy girl, aged three years, living in Norwich, came 
under the care of the late Mr. George Hutchison in the year 1873, 
having for several months previously suffered from very decided 
symptoms of stone in the bladder. It had been noticed by her 
mother that from the time of her birth she had experienced diffi- 
culty, as well as occasionally severe pain in passing urine, and that 
sometimes she voided blood mixed with it, and was in the habit of 
straining so violently as to produce prolapsus of the rectum. 

On sounding the bladder, which was an unusually capacious one, 
it was with some difficulty that a calculus could be detected. At 
the wish of the parents Mr. Hutchison resolved to remove the stone 
by dilatation. Mr. W. H. Day assisted at the operation, and I was 
requested to administer chloroform. The urethra w^as freely and 
quickly dilated with Weiss's trivalve dilator. There was considera- 
ble trouble to find the stone, and when found a still greater trouble 
to seize it with the forceps, (and it was particularly noticed that, 
although the patient was thoroughly under the influence of the 
anaesthetic, the getting hold of the stone with the forceps occasioned 
severe straining) ; the blades could not be made to grip the calcu- 
lus ; they continually slipped off, bringing away pieces of the stone. 
At last it became absolutely necessary to ascertain what occasioned 
the difficulty. For this purpose the urethra was still further dilated, 
and the neck of the bladder was also divided with a probe-pointed 
bistoury. The stone could now be felt with the point of the finger 



790 DISEASES OF WOMEN. 

immovablj fixed in the floor of the bladder on the patient's left. It 
appeared to be of the size of a pigeon's egg, and was inclosed in a 
sac, through the neck of which a small portion protruded into the 
vesical cavity, and it was off this nodule that the forceps so continu- 
ously slipped. Many efforts were made to dislodge it — first with a 
scoop, then with the finger, which could barely reach it, and next 
with the forceps ; they all proved unsuccessful. Several portions 
were broken off the uncovered portion, but the main piece was left 
in situ, as it was considered undesirable to make any further at- 
tempt to remove it, the patient having been a long time under the 
influence of chloroform, and apparently in a very exhausted con- 
dition. 

The next day the child had voided very little urine. A catheter 
was introduced, and a small quantity of sanguineous urine flowed 
out. She was very drowsy, and had been so since the operation. 
When aroused she took milk and brandy very freely, but immedi- 
ately afterward became drowsy again. She did not appear to have 
recovered from the influence of the chloroform. The next day she 
died. No post-mortem examination was permitted. 

I am induced to believe that this child died of chronic chloroform- 
poisoning, and not from the effects of the operation, which was by 
no means roughly performed, and that there was very little blood 
lost. She never thoroughly revived, but became comatose, and died 
in that condition. It is difiicult to imagine what could have given 
rise to the formation of the sac. There never was an obstruction to 
the escape of the urine, such as stricture or prostatic enlargement 
might engender, for neither existed. We are taught that a cyst is 
usually formed by the straining necessary to expel the urine ; the 
mucous membrane is forced between the bands of muscular fibers, 
hypertrophied in consequence of the strain to which they are sub- 
jected. Nothing of the sort can apply in this case, and it is not easy 
to believe that the stone was the cause of the cyst, which it might 
have been, had it been situated close to the neck of the bladder. 
When impacted in this situation, the very pressure to which a stone 
is subjected by the constant and long-continued action of the bladder 
to expel it, causes the mucous membrane to ulcerate through, and 
the stone is in due time forced into a cavity, which enlarges as the 
stone grows, and in this way it may form a tumor in the vagina. An 
effort is then made by nature to contract the opening, which in this 
child was nearly accomplished ; but the calculus was far from the 
neck of the bladder, and could barely be touched with the point of 
the finger, so that a different explanation of the formation of the 



NON"-INrLAMMATOKY DISEASES OF THE BLADDER. ^91 

cyst is required ; and as no examination was allowed to be made, it 
seems to me to be almost impossible to suggest in what way the sac 
was formed. Sabulous matter, or a few urinary crystals, may prob- 
ably have been deposited originally in a mucous follicle, lacuna, or 
fossa, and gradually augmented in quantity, and in this way the sac 
inclosing the calculus may have been produced. The mother of the 
girl at four years of age suffered from stone, which was removed by 
the late Dr. Edward Lubbock ; it was the size and shape of a wal- 
nut. She has suffered from incontinence since that time. 

I believe that it would have been very mucb better to have re- 
moved this stone by cystotomy. Had the patient lived she would 
have suffered from injured urethra. 

(c) Foreign Bodies introduced into the Bladder through the Urethra. 
— Of these it may be truly said that " their name is legion," for in 
the literature of the subject we find recorded a most numerous and 
diverse list of objects found in the bladder of the female. Some of 
these objects were forced into the bladder by accidents, such as falls 
or blows ; others were intentionally introduced into the urethra for 
the purpose of masturbation, and then pushed or drawn into the 
bladder. The same may occur in auto-catheterization, tbe instru- 
ment being sometimes broken off in the bladder, and at others, 
drawn bodily into the viscus. 

Hysterical and foolish women, with or without the intention of 
masturbating, have passed all manner of things into the bladder, as 
pins, needles, matches, sand, charcoal, bits of glass, bodkins, and 
tooth-brush handles. 

Masturbators have also forced in various articles, such as t\vigs, 
small wax candles, penholders, nails, pencils, and the like. Cathe- 
ters and clay -pipe stems, that have been used for purposes of cathe- 
terization, have been broken off and left in the bladder. 

Pessaries, which have been badly fitted, or worn too long, have 
passed by ulceration from the vagina into the bladder. 

Symptomatology. — The symptoms need not be given in detail, as 
they are the same as those caused by any foreign body, usually aggra- 
vated, however, if the body be sharp and have jagged edges. Bleed- 
ing is not uncommon, and pain varies in amount and severity with 
the kind, size, and shape of the foreign body. Hysterical women 
have been known to conceal the pain and tenesmus for a long time. 
If the bodies be small and blunt, they may give rise to but little 
pain or tenesmus, and, remaining in the bladder undisturbed, form 
nuclei for calculi. I doubt if a modification of the urinary secretion 
by reflex nerve influence (excited by these bodies) is necessary to 



792 DISEASES OF WOMEN. 

cause incrustation, or form calculi. The hypersecretion of mucus 
and decomposition of urine is all that is required. 

Treatment. — The treatment of a foreign body in the bladder is 
summed up in two words — remove it. This must first be tried 
through the tirethra. A pair of forceps (those known as the alli- 
gator forceps being the best) are guided to the object, which is to be 
seized and removed. If this is difficult, the operation may be done 
through the speculum. If the bodies be small, they may possibly 
be washed out. If they are so situated that their removal by the 
urethra is impossible, vaginal cystotomy may be performed, and the 
foreign bodies thus removed, using such after treatment as will re- 
lieve any cystitis, w^hich may have been produced. 



CHAPTER XLIY. 

NOIf-mFLAMMATOEY DISEASES OF THE BLADDER (cONTINUED). 

BUPTURE OF THE BLADDER. 

EuPTUEE of the bladder may be classified according to its loca- 
tion and extent, as follows : 

I. Complete and incomplete. 

II. {a) Occurring at a point where the bladder is co\^ered with 
peritonaeum. 

ih) Where the bladder is not covered with peritonaeum. 

I. In the complete rupture all the coats of the organ are divided, 
while in the incomplete variety one coat at least remains undivided. 

Pathology, — The complete form of rupture is the most common, 
and the location at which it most frequently occurs is the posterior 
and upper part ; that is, the part where the walls of the bladder are 
the thinnest, and probably where there is the greatest exposure to 
the causes of the injury. 

There is another reason given why rupture is more frequent 
where the bladder is covered with peritonaeum, and that is because 
the peritoneal covering is not so elastic as the other coats. 

When the laceration occurs within the limits of the peritoneal 
coat, and is complete, the urine escapes into the peritoneal cavity, 
and produces shock and peritonitis, which usually prove fatal. 

In rupture at any point not covered with peritonaeum, infiltra- 
tion of urine takes place in the tissues beneath, not within, the peri- 
tonaeum. This infiltration is sometimes very great, extending from 
the cellular tissue of the pelvis to the labia and thighs. 

The clinical history of these two varieties differs in its char- 
acteristics because of the fact just mentioned — that in the one va- 
riety the urine escapes through the rupture into the peritoneal cavity, 
while in the other the urine infiltrates the tissues in and about the 
pelvis. 

52 



794 DISEASES OF WOMEN". 

In the one, peritonitis is speedily developed, as a rule, and gen- 
erally proves fatal ; in the other, the progress is slower, and the 
chief danger is from septicoemia. There is another class of cases 
having a pathological history which holds an intermediate position 
between the two already described. 

In this class the history points to the fact that the rupture has 
been at a point destitute of peritonaeum, or else the rupture has been 
incomplete, not involving the peritonaeum. 

This gives rise to symptoms of severe internal injury, but less 
severe than in complete rupture, which is foUowed by a sudden giv- 
ing way and escape of urine into the peritoneal cavity, and subse- 
quent peritonitis. This opening into the peritoneal cavity at a pe- 
riod remote from the injury, is due to pressure or ulceration or 
sloughing, which completes the rupture. 

Symptomatology,— T\iQ symptoms of rupture of the bladder are 
ordinarily developed as follows : There is usually shock in a marked 
degree, and if the pelvic bones are broken — a frequent complication 
of this injury — the patient is unable to move after having rallied 
from the shock. Severe pain is felt in the hypogastric region, and 
a continual desire to urinate, without the power to void the smallest 
quantity of urine, or possibly but a few drops mixed with blood. 
The constitutional symptoms indicate great prostration, which rapidly 
ensues. The patient has an anxious look, the countenance is pale, 
the pulse feeble and fluttering, respiration sighing, skin clammy ; the 
abdomen in a short time becomes tympanitic. There is also a rise 
in temperature after a time, but during the shock the temperature 
may be sub-normal ; delirium, convulsions, and coma may occur, and 
death may take place in a few hours in severe cases, or it may be 
delayed a few days. A fatal result occurs sooner in complete than 
in incomplete rupture. 

If the patient survives the shock or collapse, life may be en- 
dangered by the development of peritonitis or septicaemia. The 
physical signs of rupture are few and by no means reliable. I must 
therefore give more attention to the clinical history and symptoms, 
incidentally bringing out the only physical signs obtainable, such as 
tbe empty state of the bladder found when that viscus has not been 
emptied in several hours, and the withdrawal of a small quantity of 
bloody urine by means of the catheter. 

The surgeon is not able to make a certain diagnosis in all cases, 
as the symptoms are not always pathognomonic. The statement of 
the patient that she received a blow over the hypogastrium, or that 
while in the act of straining she felt something give way, are valu- 



N0:J^-INFLAMMAT0RY diseases of the bladder. 795 

able as evidence when acute pain and otlier symptoms of rupture 
follow. 

The evidence obtained from the use of the catheter is of value, 
especially when it is known that the patient had not urinated for 
several hours prior to the accident. 

Under these circumstances when the bladder may contain a 
small quantity of bloody urine or when the bladder is empty, there 
is strong evidence of the bladder being lacerated. But the evidence 
pointing to rupture is by no means always certain. And again very 
often signs and symptoms which the diagnostician depends upon 
most are absent, and those that are present are liable to mislead. 
This is very unfortunate, but true. The diagnosis is especially ob- 
scure when there has been a long interval between the receipt of the 
injury and the development of characteristic symptoms. It is there- 
fore necessary to watch a patient in whom there is suspicion that 
rupture of the bladder may have occurred. The symptoms may be 
for a time concealed and then develop rapidly. The first symptoms 
may be delayed or be obscure and not attract attention, because the 
vesical rupture may be involved with other injuries whose symp- 
toms for the time hide the more dangerous lesions. As a rule, it is 
rare to find any external signs or mark of injury on examination of 
the abdomen. When much depends on the history given hy the 
patient regarding the nature of the accident and the condition of 
the bladder at the time, it frequently happens that she is not able 
to answer questions correctly, because of the shock and the fact that 
this accident often occurs while the patient is intoxicated. 

Strange as it may appear, in exceptional cases the patient may 
have no difficulty in urinating, and indeed may pass a large quan- 
tity of water. Cases have been recorded where the patient regained 
the power of voluntary urination after the catheter was passed for 
the first time. 

Although it is important to make a diagnosis early in all cases, 
yet it is of equal importance to know whether the rupture is com- 
plete or incomplete. This can be done by noting the fact that in 
the one case there will be infiltration of the urine into the cellular 
tissue of the pelvis, and in the other such infiltration is absent. 

It is often necessary to pass the catheter both for diagnosis and 
treatment, and great care should be taken in its introduction, for 
sometimes by using too much force it is accidently pushed through 
the viscus into the abdominal cavity. 

Prognosis. — The chances of recovery are not favorable, espe- 
cially when the urine passes into the peritoneal cavity through a 



796 DISEASES OF WOMEN". 

rupture Mgli up. "When the rupture is incomplete or does not in- 
vol\^e the peritoneal coat and treatment is early employed, the pros- 
pects of saving the life of the patient are encouraging. 

Causation. — The predisposing causes of rupture are certain con- 
ditions of the walls of the bladder, such as atrophy, fatty degenera- 
tion, ulceration, and sacculation ; overdistention from stricture or 
other causes, and alcoholic intoxication which favors overdisten- 
tion, and exposure to the exciting causes of the accident. The 
empty bladder may be lacerated in connection with injuries of the 
other pelvic organs, but it is a fact that in the majority of cases the 
bladder has been less or more distended at the time of the accident. 
It should be borne in mind, however, that rupture has occurred a 
great many times when the bladder was normal and not overdis- 
tended, there being no predisposing conditions present that could 
be recognized. The most common determining causes are blows 
over the region of the bladder. These may be sustained in a 
variety of ways, such as direct blows or knocks, falling from a 
height upon something which violently strikes upon the hypogas- 
trium. Kupture often occurs in connection with severe injuries 
which fracture the pelvic veins. In such cases it is not possible to 
say whether the rupture occurring under such circumstances is due 
to the direct blow or to laceration by pieces of the broken bones. 

Rupture has occurred sufficiently often in the puerperal state to 
warrant placing this condition in the list of predisposing causes. 
One can see how a distended bladder might be ruptured during 
the violent labor -pains or the contortions of instrumental and 
manual delivery, and this accident has occurred in that way. In 
a number of cases, however, the rupture has not taken place un- 
til after delivery, showing that the labor gave rise to retention, and 
that to rupture. So far, then, as the puerperal state is related to 
rupture of the bladder it may be said that a full bladder may be 
ruptured by the direct violence done during delivery, but quite as 
often retention occurs in the puerperal state, and the rupture is 
caused by overdistention. In a similar way rupture has occurred 
in displacement of the uterus which caused retention of the urine. 

The bladder has frequently been wounded during ovariotomy 
and hysterectomy when there were adhesions, but this accident does 
not come under the head of rupture now under consideration. 

Treatment — The first indications are to reheve pain and shock 
if either is present. These objects can be attained usually by opium 
and stimulants. If there is infiltration of urine into the pelvic 
ceUular tissue the urine should be removed by puncturing or incis- 



NON-INFLAMMATORY DISEASES OF THE BLADDER. 797 

ing the parts affected. ]^ext, and most important of all, the bladder 
should be continuously kept empty by retaining the catheter in 
the bladder. The catheter should be a flexible one of soft rubber 
with a perfect eye very near the end. It should be made to enter 
the bladder only far enough to secure perfect drainage and not far 
enough to disturb the wound in the bladder. Yaginal cystotomy 
has been recommended as a means of drainage, but I feel sure that 
the catheter is a simpler, and certainly as reliable a means of accom- 
plishing the object. The management of the graver cases, in which 
the rupture opens into the peritoneal cavity, must be of the most 
heroic character in order to be effectual. 

The great object is to cleanse the peritoneal cavity of urine and 
blood. This has been done when the case was seen early, by pass- 
ing the catheter into the peritoneal cavity through the rent in the 
bladder. When this can be done easily it may answer that purpose, 
and the patient may be treated by rest and opium ; but, unless the 
catheter passes without much effort and the one catheterization is 
sufficient, this method should not be persisted in. 

Laparotomy appears to offer the best chances in these very for- 
midable cases. If the patient is seen early, and before extensive 
peritonitis has been established, I believe the best that can be done 
is to open the abdominal cavity, and thoroughly remove all blood 
and urine that have accumulated. When this has been accom- 
plished the wound in the bladder should be accurately closed with 
sutures. In case the edges of the wound are very irregular, and 
will not fit together accurately, they should be trimmed suffi- 
ciently to give a clean and complete coaptation. The after-treat- 
ment should then consist in draining the bladder, as already 
mentioned, and managing the patient as in laparotomy for any 
purpose. 

ILLUSTRATIVE CASES. 

Case of Rupture of Female Bladder associated with Abortion (by T. 
Lawrie Gentles, L. F. P. S. G., Derby).— On October 13th I was 
requested, at 3 a. m., to visit a woman in a neighboring street, who 
was said by the messenger (her husband) ''to have had a mishap." 

On reaching the house I found a well-made woman of thirty-six 
lying on her left side in bed, vomiting large quantities of a dark- 
brown, pungent-smelling liquid. The pillows were drenched with 
the fluid, so also was the carpet in front of the bed, and on the walls 
opposite to the patient were stains of a similar nature. There was 
also haK a pint of vomit in the chamber- vessel. The woman was in 



798 DISEASES OF WOMEi?". 

a state of collapse ; a cold, clammj perspiration stood on her face, 
her hands and feet were like ice, and her pulse was imperceptible. 
There was no one in the house except her husband and two little 
children, the latter occupying the same bed as the patient ; while, to 
add still more to the ghastliuess of the scene, the younger of the 
children (a babe of nine months) was vainly endeavoring to reach its 
dying mother's breast in order to obtain its usual nourishment. 

I made a rapid examination by the vagina, but found a closed 
OS uteri, and no marked traces of haemorrhage. I observed, however, 
that the abdomen was greatly distended. I tried to administer some 
ammonia, but the patient was unable to swallow ; she gave me one 
agonizing look of dread, moved her lips as if to speak, and then died, 
tJie death taking place within a quarter of an hour after my arrival 
at the house. 

My first impression was that the woman had died of internal 
haemorrhage ; the only things which seemed to mihtate against this 
being the redness of the lips and the copious vomiting. This idea 
of haemorrhage seemed also confirmed by what the husband said at 
the bedside — viz., that " his wife had had a good many clots come 
from her, and that her linen was very much stained." 

I refused, of course, to give any certificate, and communicated 
with the coroner. In collecting evidence for the inquest, the follow- 
ing facts were clearly brought out ; first, that the woman was a 
drinker ; secondly, that she had had a drinking-bout for some days ;' 
and thirdly, that she had had occasional difficulty in passing urine. 
In regard to the first two points, the husband's evidence was most 
conclusive, and showed clearly that when the poor woman had one 
of her drinking-fits on, she would not only consume large quantities 
of beer (her favorite drink), but also all the spirituous liquors she 
could lay her hands on. In regard to the third point, the hus- 
band also made clear the fact that his wife had often suffered from 
retention of urine, but, " so far, had always got over it." At the 
inquest, further details of evidence brought to light the fact that the 
woman had complained of pain in her belly for two or three days 
previous to death. She had, however, been " up and down stairs " 
until 1 p. M. of the day preceding her death ; but when her husband 
came home at 6 p. m., he found her in great pain, and was told by 
his wife that ''she had been losing blood." A good many clots 
were in the chamber-vessel, and these he threw away into the ash- 
pit. The pain getting no better, and finding that his wife was 
"altering for the worse," he came for a medical man as already 
stated. 



NOX-INFLAMMATOEY DISEASES OF THE BLADDEE. 799 

At the autopsy there were no external signs of violence found, 
except a slight abrasion on the forehead, and another on the lower 
lip, and a small bruise on the inner side of the right thigh, none of 
which were of recent date. On cutting through the abdominal walls, 
the great depth of fat and its extreme " wateriness " arrested onr at- 
tention, the knife going through the tissue with a distinct " swish." 
Suspecting an accumulation of fluid in the abdominal cavity, a small 
incision was made at first. No sooner was this done than a reddish- 
brown liquid began to well up. Some of this was drawn off, and the 
opening enlarged, when nearly six pints of fluid were removed. The 
stomach and intestines, having been carefully examined, were then 
taken out, in order to facilitate further search for the lesion. The 
first thing which we noticed was a pint of blood lying in the pelvic 
basin ; and, on making more minute search, a rent was discovered in 
the posterior wall of the bladder — a rent large enough to admit four 
fingers. Here, then, was the cause of death. There were some 
fresh adhesions on each side of the bladder and the pelvic walls; 
there were also similar adhesions between the bladder and uterus. 
All these adhesions, however, were extremely soft, and broke with 
the slightest pressure. The walls of the bladder itself also seemed 
much thinner than usual. 'No flakes of lymph could be discovered 
in the fluid removed from the abdominal cavity, and neither did 
the peritonaeum exhibit any great degree of vascularity. It may be, 
however, I think, safely affirmed that a large portion of the fluid 
found was effused from an irritated peritonaeum, the other portion 
of the fluid being, of course, urine from the ruptured bladder. 

On opening the uterus, signs of recent delivery presented them- 
selves ; on observing which I asked my son to tell the husband to 
rake up " the clots " from the ash-pit. The husband did so, and one 
of the " clots " was found to be a foetus, three inches in length. 

Now comes the question : When did the rupture of the bladder 
occur, and had uterine action anything to do with it ? Supposing 
that the ''pains in the belly," of which the woman complained for 
two or three days before death were the commencement of the 
abortion, it is reasonable to infer that, when true expulsive efforts 
on the part of the uterus began, these efforts would be aided by the 
action of the abdominal muscles ; and, supposing still further, that 
the bladder was at that time distended to its fullest capacity, it is 
perfectly possible that the pressure of the abdominal muscles would 
be the "last straw" necessary to produce the fatal lesion. I am, 
therefore, inclined to think that the rupture took place in the after- 
noon of the 12th. I ought to have stated that, although, when the 



800 DISEASES OF WOMEN. 

husband came home at 6 p. m. on that day he found his wife in bed, 
she, nevertheless, " kept getting out of bed, trying to pass urine, but 
could not." There can be httle doubt that the alcoholic condition 
of the patient would rob her of her sense of attending to the calls of 
nature ; and it is melancholy to think that, if she had only been seen 
earlier, a simple catheterism might have saved her. 

As a piece of concurrent evidence of the habits of the patient, it 
may be stated that the liver was a genuine " nutmeg " ; that the 
kidneys were thoroughly disorganized (the cortical substance being 
rarely distinguishable) ; and that the spleen was exceedingly soft. 
The heart was small and fatty. The lungs were fairly healthy, but 
there were extensive adhesions in the right pleural cavity. The 
head was not examined. — British Medical Journal^ January 6, 
1883. 

Cases of Rupture treated by Laparotomy. — (A. G. Walter ) — Ten 
hours after a severe injury, no urine was found by the catheter. The 
abdomen was opened in the linea alba by an incision beginning one 
inch below the umbilicus and terminating one inch above the pubes, 
to the extent of six inches. The intestines were found inflated, 
their peritoneal coat, as well as that hning the interior of the ab- 
dominal walls, already showing evident marks of congestion. A 
soft sponge was then cautiously introduced into the abdomen, with 
which the extravasated fluid, consisting of urine and blood, was 
carefully removed from the pelvis and between the convolutions of 
the bowels, amounting to nearly a pint. A rent was found at the 
fundus of the bladder, two inches in extent. The cavity of the ab- 
domen being cleansed of the noxious agent, the wound of the blad- 
der was left to itself, as no urine was seen to escape from it. The 
abdominal wound was closed by strong Carlsbad needles, secured by 
silver wire (only skin and fascia being stitched, while the peritonaeum 
was left untouched) ; a flannel bandage encircled the whole abdomen. 
The patient, awakening from the anaesthetic sleep, felt relieved of 
pain and the desire to urinate, so distressing before the operation ; 
vomiting did not return ; opium in one-grain doses was ordered ; 
abstinence of drink and perfect quietude of body, with retention of 
the catheter, were strictly insisted upon. He soon began to doze, 
had a comfortable night, was free from pain the next morning, com- 
plaining only of soreness in the abdomen, without tympanites, sick- 
ness, or calls to urinate; thirst less urgent. The treatment being 
vigorously continued, for drinks iced barley-water, water only in 
very small quantities, with pieces of ice, being allowed, l^o un- 
pleasant symptom followed ; urine in small quantities, but free of 



NON-INFLAMMATORY DISEASES OF TEE BLADDER. 801 

the admixture of blood, passing by the catheter. On the third day 
the intervals between the doses of opium were lengthened to two 
hours; on the fifth, to three, and thus gradually decreased as all signs 
of inflammation had passed. At the end of a week the abdominal 
wound appeared to be closed by first intention ; the stitches, however, 
were not removed till a week later. The gum-elastic catheter was 
replaced by a new one every two days, and was not withdrawn for 
two weeks after the injury had been received, and then only for a 
short time. At the expiration of two weeks, with the absence of all 
pain and tenderness, opium was omitted. The intestines were re- 
lieved by warm-w^ater injections on the tenth day, when mild nour- 
ishment was ordered. Between the second and third week the 
catheter was permanently withdrawn, and only introduced every 
four hours for the evacuation of urine. After the third week, the 
patient left his bed. He has remained well, working at his trade, 
and feeling no impediment in his urinary organs. 

(Alfred Willett). — An incision some five to six inches in length, 
from the umbilicus to the pubes, was made in the mesial line and 
carried through the parietes. All bleeding points having been se- 
cured, the peritongeum was opened, and at once several ounces of 
dull, brownish fluid, with strong urinous odor, escaped. The intes- 
tines were greatly distended, and instantly bulged out through the 
wound. The peritonaeum generally was highly injected, and adja- 
cent surfaces were glued together. Passing my hand into the pelvis 
I detected a laceration of the bladder. The coils of gut were only 
slightly more adherent here than in the abdomen proper ; I satis- 
fied myself that there was no protrusion of bowel into the lacerated 
bladder. The omentum was raised from o£E the intestines, and so 
much of the latter as lay in the pelvis was drawn up, laid upon the 
upper part of the patient's abdomen, and protected from harm and 
chill by flannels wrung out of moderately hot water. There was 
about half a pint of bloody, urinous fluid in the pelvis, and when 
this had been sponged away, a rent of the bladder some three and one 
half inches in extent was exposed. It extended diagonally across the 
fundus, having a direction from before backward and from right to left. 
The appearance was that of a nearly straight tear through all the 
coats of the bladder, except at its most dependent parts, where it was 
jagged and uneven. The bladder w^as flaccid, but, of course, quite 
empty, and at the site of rupture its walls were fully half an inch in 
thickness. I brought the torn edges easily in apposition, and united 
them by eight interrupted sutures of fine Chinese silk. The sutures 
were placed at intervals of rather less than half an inch, and seemed 



802 DISEASES OF WOMEN. 

to close the rent completely. Before returning the intestines I 
cleaned out the abdomen as thoroughly as I was able ; but the mes- 
entery of the gut lying outside the abdomen acted as a transverse 
diaphragm, and I was disappointed to find on replacing these coils 
that some of the fluid had been pent up above it. Owing to gaseous 
distention, very considerable difficulty was experienced in replacing 
all the intestines within the abdomen, and I was quite unable to in- 
troduce my hand and cleanse the upper part of the peritoneal cavity 
as satisfactorily as I could have wished ; but the patient's shoulders 
were raised in order to make the pelvis more dependent, and all fluid 
that found its way there was removed. The intestines that had been 
lying out of the abdomen during the operation were sponged over 
with warm water and carefully cleansed before returning them. So 
extreme was their distention that to enable me to introduce sutures, 
and close the external wound, Mr. Langton, who assisted me, was 
obliged to spread out his hand and restrain the bowels from forcing 
their way through the wound, withdrawing his hand gradually as the 
successive sutures, also of Chinese silk, were tightened. Through 
the lower angle of the abdominal wound I passed a carbolized drain- 
age-tubs into the pelvis, securing it to the edge of the external 
wound, which was then dressed precisely as after ovariotomy. A 
Thompson's catheter was introduced and retained in the bladder. On 
being replaced in bed, hot bottles were placed beside the patient, and 
he was well covered up. The wound in the abdominal parietes was 
found on the autopsy to be adherent almost along its whole line ; not 
much swelling of abdomen. The intestines immediately behind the 
wound were adherent to it. All the coils of intestine in the lower half 
of the abdomen were adherent to each other and to the abdominal 
walls by recent lymph. The intestines in contact with the bladder 
were adherent to it. There were about two ounces of bloody fluid at 
the back of the peritoneal cavity ; about an ounce of this lay just 
above the bladder. The opening in the bladder was everywhere well 
closed, except between the posterior two stitches, where there was an 
orifice through which water injected per urethram escaped very freely. 
Even here there appeared to be an attempt at repair. Elsewhere the 
edges of the wound were adherent. There was very little sign of 
inflammation in the interior of the viscus. 

(Christopher Heatli). — Man, aged forty-seven. Pubes being 
shaved and washed with carbolic lotion, an incision was made in the 
middle line just above the pubes for two inches, and the tissues 
divided down to the peritongeum, which appeared blue, the recti mus- 
cles, which were firmly contracted, being held aside by retractors 



NON-INFLAMMATORY DISEASES OF THE BLADDER. 803 

with difficulty. The peritongeum was then picked up and a cut made 
into it, when a gush of fluid, like that drawn off by the catheter, 
came out. A large quantity of clots was then taken out from the 
peritoneal cavity. The finger introduced into the peritoneal cavity 
found a long rent in the posterior wall of the bladder high up. This 
was sewed up by a continuous catgut suture firmly tied at both ends. 
The clots were removed as far as possible from the peritonaeum, and 
the cavity sponged out after injection with warm water, and a long 
large-sized drainage-tube was inserted at the lower angle of the 
wound, the upper part of the wound being brought together by deep 
and superficial sutures. A catheter was passed into the bladder, to 
w^hich was afterward attached some India-rubber tubing leading into 
a vessel under the bed. Hot poultices were applied to the abdomen, 
and one grain of opium was administered every four hours. The fur- 
ther history shows great relief and improvement, but on the fourth 
day after the operation the patient became rapidly worse and died. 
Autopsy. — Small intestines considerably distended. For two inches 
around the abdominal wound the intestines were adherent by recent 
lymph to each other, and to the abdominal parietes. Above and on 
each side of these adhesions there was no trace of peritonitis. On 
tearing away these adhesions some coils of intestines were seen lying 
over the pelvis glued together, and to adjacent parts by recent blood- 
stained lymph. On lifting these coils upward, the recto-vesical 
pouch of peritonseam was exposed, containing about six ounces of 
clotted blood, black in color, and moderately offensive odor. There 
was a rent in the mid line of the posterior wall of the bladder two 
inches in length, extending upward as high as the apex. The lower 
third of the rent was gaping ; the edges of the rest w^ere approxi- 
mated by the catgut suture, the lower end of which was free and 
loose. 



CHAPTEK XLY. 

NON-INFLAMMATOET DISEASES OF THE BLADDER (cONTrN"UED). 
NEOPLASMS, HYPERPLASIA, ATROPHY. 

Owing to the very imperfect facilities for observing the internal 
surface of the bladder during life, the study of vesical neoplasnas 
up to within a few years was chiefly post-mortem, and of course 
their therapeutics was almost nil. At the present time, however, 
by means of the endoscope, the microscope, and the operation of 
cystotomy, more accurate methods of diagnosis and of rational and 
successful treatment have been developed. 

The neoplasms of the bladder may be classified as follows : 

Benign. — Myxoma, fibroma, myoma, myo-fibroma, tubercle. 

Malignant. — Epithelioma, encephaloid, scirrhus, sarcoma. 

Tumors of the bladder and deposits in its walls are by no means 
common, and those of a benign nature are less common than those 
that are malignant. There has been some dispute as to whether 
some of these neoplasms are malignant. This is especially the 
case in regard to the villous growth, the German and some 
English authorities ranking them as essentially malignant, while 
some American authors, as Van Buren and Keyes, deny in toto that 
they have any such property. More will be said of this when I 
come to the class in which I have placed them ; not that I am satis- 
fied that they are malignant, but for lack of positive evidence of the 
new idea, temporarily at least, I adhere to the old one. 

Benign Growths. — Myxomata, Mucous Polypi, and Polypoid Hy- 
pertrophies, while having nearly the same anatomical characters, are 
really different affections as regards etiology, symptomatology, prog- 
nosis, and treatment. 

Mucous polypi are isolated hypertrophies of the mucous mem- 
brane, varying in size, and giving rise to trouble only in proportion 
to their size. They may exist at birth, or be developed at any time 
during life, being more common, however, in youth and middle 



NON-INFLAMMATOKY DISEASES OF THE BLADDER. 805 

age. The mucous membrane covering them is thickened and pulpy, 
and that about their base and in their immediate neighborhood is 
somewhat thickened, and more vascular than normal. If the polypi 
are situated at or near the neck, or in other portions of the bladder, 
where their long, narrow pedicles admit of a blocking of the urethra, 
the entire mucous membrane of the organ suffers, as in all cases of 
retention and decomposition of urine. If the obstruction is great, 
and the organ requires spasmodic and irregular muscular effort to 
empty it, there will be, sooner or later, not only cystitis, but mus- 
cular as well as mucous hypertrophy. 

These growths may be as small as the head of a pin, or as large as a 
goose-egg ; they consist of hypertrophied and hyperplastic connective 
tissue, covered by soft, pulpy, hyperplastic mucous membrane, that 
bleeds easily on touch. They may coexist with uterine fibroids. 
Their favorite seat is the posterior wall of the bladder. 

General polypoid hypertrophy of the mucous membrane con- 
sists in an irregular thickening of the mucous membrane through- 
out, accompanied as a rule by hypertrophy of the muscular and 
serous coats. There is an increased blood-supply, the membrane be- 
ing bright red in color, the capillaries dilated, and the whole mass 
bleeding easily on the touch. It has somewhat the appearance of 
fresh granulations. Upon the free surface of the mucous membrane, 
there is, as we should expect, an excessive cell proliferation, these 
cells being in a transitional condition, i. e., occupying the position 
between imperfect and perfect, and not all of the same degree of 
perfection or imperfection of development. There may be either 
serous or gelatinous infiltration, giving it a heavy, sodden look. 
Upon the surface are often found incrustations of the urinary salts. 

It appears to me that there has been an undue complexity of 
classification of this subject, especially among the G-erraan patho- 
logists, some of whose differences are too minute to be of any prac- 
tical value from either a pathological, diagnostic, or remedial point of 
view. Tumors which they call villous or papilloma vesicae are, in 
many, if not all respects, identical with the so-called polypoid hyper- 
trophy of the vesical mucous membrane. For all practical purposes 
they are essentially the same. 

They have been described as enlarged papillae, the vessels of 
which are dilated, and their walls thinned. They only differ from 
the polypoid hypertrophy in increase of vascularity, and the fact 
that they are usually limited to the trigone. Underlying and about 
them is a thin, wavy stroma of connective tissue, that becomes in- 
creased as the disease advances. 



S06 DISEASES OF WOMEX. 

The surface of these growths varies very much in different cases ; 
in some looking like large granulations, in others having more body, 
being more compact, and looking somewhat like a raspberry or mul- 
berry. Occasionally, they are slightly pedunculated. Their surface 
has an epithehum resembling the superficial layer of the bladder, 
unless proliferation is very rapid, when the cells lose their identity, 
and take a multiplicity of forms, to which may be attributed, perhaps, 
their having sometimes been mistaken for cancer cells when found 
in the urine. Fatty degeneration of the most superficial cells is by 
no means uncommon. As the villi increase in size and number, the 
connective-tissue stroma, while increasing about their base, dimin- 
ishes in the prolongations themselves, leaving little besides a mass 
of tortuous, thin-walled, dilated vessels hanging free in the bladder. 
The rest of the mucous membrane is usually soft and hyperplastic, 
and, if there be any stoppage to the free outflow of urine, infl.amma- 
tion may coexist, with incrustations, and possibly dilatation of the 
ureters. The muscular coat is also usually slightly hypertrophied. 

Fibroid tumors and myo-fibromata are very rarely found in the 
bladder. When they do exist they have all the characters of the 
fibroma or myo-fibroma found elsewhere, and give rise to the same 
changes in the vesical walls and ureters that other tumors do, viz., 
retention with hypertrophy, or dilatation, cystitis, and inflammation 
of the ureter. They may have their seat in any part of the bladder- 
wall, and occur at any period of life. 

Symptomatology, — The symptoms of vesical neoplasms are di- 
visible into local and constitutional ; the former being by far the 
more important. The local symptoms, if the tumors be of any size, 
are those produced by a foreign body in the organ, viz., irritation, 
and sooner or later inflammation. 

Obstruction to urination sometimes occurs when the tumors are 
in a position to block the urethra, and by the sloughing off or de- 
tachment of small fragments, which may or may not be incrusted. 
These are forced into the urethra, and obstruct the outflow of 
urine. 

Pain in one form or another is almost always present. It may 
consist of a simple uneasiness in the hypogastric region, or amount 
to actual pain. It may have its seat in the hypogastric region in the 
peringeum, or more rarely at the end of the urethra. It may also be 
felt in the loins, or along the thigh and knee. It is usually more 
intense, as all the symptoms are, during the menstrual flow. This 
is not so in all cases. 

Frequent urination and vesical tenesmus are as a rule present. 



NOJl^-INFLAMMATORY DISEASES OF THE BLADDER, 807 

but are not proportionate to the size of the tumor, a very small neo- 
plasm often giving rise to most intense spasm. 

Haemorrhage is by no means infrequent, and in some cases is 
very severe and not readily checked ; in others it is slight, simply 
tinging the urine or imparting to it a smoky appearance, that is 
characteristic of the presence of a small amount of blood or blood- 
coloring matter in acid urine. When the hsemorrhage is extensive, 
and the bladder is distended by the fluid or clotted blood, retention 
of urine is apt to occur, and sometimes obstructive suppression, that 
may lead to most serious results. 

Hsematuria is as liable to occur with the benign as with the ma- 
lignant growths, and consequently is of little value in difiierential 
diagnosis. The effects of prolonged or repeated haemorrhage upon 
the constitution are often most serious, and the patients are apt to 
be anaemic and also cachectic in appearance. I have had one case in 
which haemorrhage was the only symptom present. 

The presence of the foreign body in the organ soon gives rise to 
inflammation, which is seriously aggravated if retention accompany 
it. The urine is then found loaded with mucus, muco-purulent or 
purulent matter, epithelial scales, tissue shreds, bits of tumor, and 
the triple and amorphous phosphates. 

Intense and repeated vesical tenesmus aggravates the inflamed 
condition of the membrane, and after a time leads to muscular hyper- 
trophy and increased haemorrhage. 

In these cases, as in cystitis from any other cause, dilatation of 
the ureters, with a traveling upward of the inflammation and destruc- 
tion of the kidney, may result. This dilatation and the evil after- 
results are more apt to occur if the neoplasm be of sufficient size to 
obstruct the free outflow of urine, as at every spasmodic and forcible 
contraction of the hypertrophied organ some urine is dammed back 
in the ureters, dilating them gradually. When the ureteric openings 
are dilated, so that urine regurgitates at each vesical contraction, 
serious lesions result, as ureteritis, pyonephrosis, renal abscess, or, if 
the process be slow, gradual renal atrophy, uraemia, and Anally 
death. 

The general system may or may not suffer severely for a long 
time. In most cases it does. The usual train of symptoms, such as 
loss of sleep, disorder of digestion, sweating, and blood contamina- 
tion are developed in regular sequence. The patients become thin, 
and have a worn, anxious expression, and, as I have already said, are 
apt to be both anaemic and cachectic. 

If renal troubles complicate this affection, casts, renal cells, and 



808 DISEASES OF WOMEN". 

albumen may appear in the urine. In renal abscess-atrophy, or pyo- 
nephrosis, however, the urine may be examined for weeks without 
showing any renal tissue, casts, or epithelium, there being simply an 
abundance of pus. 

Diagnosis. — The diagnosis of vesical neoplasms is made chiefly 
by physical signs. The methods employed in their investigation 
may be arranged under two heads. 

Direct. — Bimanual touch, speculum, endoscope, curette, catheter, 
palpation. 

Indirect. — Urine. 

Direct. — An intelligent employment of the methods classed under 
the first head is all that is necessary to make a clear diagnosis in 
some cases. The bimanual touch will reveal the presence of the 
tumor, if it is of any great size, and also its size and fixation in one 
place. This fixed position is of much importance as distinguishing 
a neoplasm from other foreign bodies, stone, for example, which is 
movable, and can be pushed from one side of the bladder to the 
other. The use of the endoscope will show at once the appearance 
of the tumor, if it is favorably located, and by scraping away a little 
with the curette (through the speculum), its nature may be discov- 
ered by a microscopical examination. • 

The use of the catheter or finger in the bladder, or one in the 
bladder and the other in the vagina, may be resorted to in cases 
where the diagnosis is difficult. But these are extremely painful 
manipulations, are not free from danger, and, consequently, should 
not be resorted to unless there is failure by other means. 

Indirect. — An examination of the urine in these cases will lead 
to the suspicion of the presence of some neoplasm in the bladder, 
from the occurrence of tissue shreds and bits of the tumor in this 
fluid. A piece of tumor will sometimes become detached and be 
expelled with the urine, and by careful searching it may be found. 
This can be placed under the microscope, and thus the examiner 
may be able to tell exactly what kind of a growth exists. 

Prognosis. — With our present means for exploring and operat- 
ing upon the inside of the female bladder, the prognosis of benign 
neoplasms is very good, if the operation for removal be performed 
early enough in the disease. Operation, however, at any time gives 
promise of good result. 

There is danger of relapse, as we learn from the cases of Simon, 
Hutchinson, and others. If the operation be carefully done, even 
incontinence of urine may be avoided, and complete, and permanent 
recovery follow. Without operation patients have lived as long as 



NON-INFLAMMATORY DISEASES OF THE BLADDER. 809 

nineteen years, in some eases suffering but little ; and it may be 
well to say that not all of these cases are accompanied by cystitis, a 
little pus and blood in the urine at intervals, with occasional frag- 
ments of tumor, being all that is found. 

Causation. — The causes of these neoplasms are vqyj obscure, in- 
deed, no definite facts can be adduced in favor of any of the causes 
given by the various authors. Some speak of them as due to the 
irritation of calculi, calculous fragments, and incrustations. These, 
however, raay be readily secondary to and produced by the neo- 
plasm, being the effect rather than the cause. Moreover, it is 
known that while persons carrying foreign bodies of various kinds in 
the bladder for a length of time, are very apt to have cystitis, neo- 
plasms are seldom found, and are very rare under any circumstances. 

Some authors look, with a show of reason, I think, to the irrita- 
tion from blood transudations into the bladder-walls, as a cause. 
This is borne out by two well-authenticated cases occurring, one in 
the practice of Hutchinson, of England, the other in that of Winckel, 
of Germany. The etiology of these neoplasms needs further care- 
ful study, before any cause or causes can be pronounced upon with 
certainty. The free and intelligent use of the modern means of 
physical exploration in all affections of the female bladder will in a 
few years throw much light upon this subject. 

Treatraent, — There is really but one form of treatment for 
these benign neoplasms, viz., removal. The method will differ 
with the size of the growth. If the tumor be not of large size, it 
may be seen, reached, and removed through the urethra. This may 
be accomplished by twisting it off by means of a pair of forceps, 
ligating its pedicle, and allowing it to slough off or by passing the 
wire of the galvano-cautery around it. If the pedicle be not suffi- 
ciently distinct, or the mass too soft to come away in mass, it may 
be broken down and removed in pieces, either by the finger and for- 
ceps, or by the curette and forceps. The haemorrhage, which as a 
rule is not great, may be controlled by injections of iced water, ice 
to the pubes, and sometimes by tamponing the vagina. Some oper- 
ators have found it necessary to apply directly to the bleeding sur- 
face the liquor ferri sesqui-chloridi (Braxton Hicks). 

The after treatment consists in washing out the organ thoroughly 
yet carefully with warm water to which may be added salicylic acid 
(1 part to 60). The pain may be controlled by opium, either by 
the mouth or rectum. The urine should be kept slightly alkaline, 
and under no circumstances allowed to remain in the bladder long 
enough to decompose and irritate or overdisteud it. 
53 



810 DISEASES OF WOMEN. 

If tlie tumor is too large to admit of removal j^er urethram Si- 
mon's operation sliould be resorted to. Also in cases where the tumor 
is so situated as to be beyond the operator's reach through the ure- 
thra. I have already fully described this operation. A T-incision 
is made into the anterior vaginal wall, the bladder opened, inverted 
through the opening, and the tumor is thus brought into easy posi- 
tion for any operative procedure. When removed, its base may be 
cauterized, and the bladder replaced. When the surface has entirely 
healed, the wound in the vesico-vaginal septum may be closed. 
Union soon takes place in most of these cases, if not interfered 
with. The after treatment should be the same as w^hen the tumor is 
removed through the urethra. 

I need hardly say that when the general system is below par, it 
should be attended to. 

Polypus of the Bladder.— Dr. Godson showed a polypus which he 
had recently removed from a woman aged sixty, who was under his 
care in St. Bartholomew's Hospital. He first saw her a year ago, 
when she complained of bleeding from the vagina. The uterus and 
vagina were found healthy, there had been no recurrence of the 
haemorrhage until a week since when the patient again presented 
herself. On examination a tumor the size of a walnut was found 
at the orifice of the vagina. It had at first sight the aspect of a 
firm fibrinous clot ; it was discovered, however, to protrude from 
the urethra, and to be connected by a narrow pedicle with the fun- 
dus of the bladder, which organ it partially inverted. Dr. Godson 
applied a catgnt ligature, and separated it with scissors. A micro- 
scopical examination showed it to consist of fibro-cellular tissue, 
with a few muscular fibers covered over with mucous membrane. 
Such polypi are of extreme rarity, and it was fortunate that the 
subject of it was a woman. — {Ohstetrical Journal, Ajpi'il 1879, 
p, ^8). 

Excision of Papilloma of Bladder. — M. C, aged thirty -four, was 
admitted to the St. Mary's Hospital, under the care of Mr. ]^orton, 
suffering from the effect of long- continued haemorrhage of the 
bladder. On examination per urethram, a tumor one inch square, 
coated with phosphatic calculus, but not much raised above the 
mucous membrane, was discovered occupying the trigone about haK 
an inch from the sphincter. It was evident that the tumor must be 
removed, and the patient submitted to the risks attendant upon a 
severe operation, or she must be left to endure the tortures brought 
about by the contractions of the bladder upon the growth after 
micturition, and with the certainty of an early death from haemor- 



NON-INFLAMMATORY DISEASES OF THE BLADDER. 811 

rhage or from blood-poisoning. It was impossible to remove the 
growth through the urethra, and it was decided to cut the mass away 
by opening the vagina. It w^as considered that the grow^th could 
not be cleared without cutting through the urethra, and the opera- 
tion was performed as follows : The spring-scissors were inserted, 
one blade into the bladder nearly up to the tumor and the other 
into the vagina, and closed ; the front wall of the vagina w*as then 
incised centrally to within half an inch of the uterus, and the vaginal 
wall, which was found not to be incorporated with the growth was 
dissected from the bladder ; the growth was then seized with the 
vulsellum forceps, and drawn forward, and was then excised by the 
scissors and removed. Bleeding was averted by the actual cautery, 
and the lateral flaps of the vagina approximated by sutures. To 
prevent further haemorrhage a catheter was inserted, and the bladder 
compressed by plugging the vagina; no haemorrhage of importance 
took place. The temperature remained below normal, and the 
pulse rose to 120. Severe vomiting persisted until the tenth day 
after the operation, w^hen she was considered out of danger. On 
the twelfth day, when apparently in health, she vomited, and shortly 
afterward fell asleep, in which sleep she died from syncope. At 
the autopsy the wound was green, and sloughing upon the surface, 
but healthy immediately beneath. No peritonitis or cellulitis was 
present, or any thrombosis of vesical, pelvic, or iliac veins. A 
microscopical examination showed the tumor to be a papilloma. 
Since writing this case Mr. I^orton had operated upon a second case 
of tumor of the bladder, w^hich had completely recovered from the 
effects of the operation. — The Medical Press and Circular^ May 
IJ}., 1879; and Medical Record, July 26, 1879, jpp 82 and 83, 

Tubercle of the Bladder. — Tubercle of the female bladder is a 
comparatively rare affection. Winckel, of Germany, in 2,505 
autopsies, found it but four times. Though not often existing as an 
accompaniment of pulmonary tuberculosis, it does not occur alone, 
but is usually accompanied by similar deposits in the intestines, 
kidneys, liver, and elsewhere. It is usually found in early life, 
though cases have been recorded where it occurred as late as the 
sixty-fifth year. 

The favorite site for its first appearance is at the vesical neck, or 
about the meatus urinarius, these places being rich in minute glands 
and follicles. The deposits appear as minute white or yellowish 
white points on a red, indurated base. After a time, owing to their 
coalescing and breaking down, large spots of ulceration result. 

With these deposits in the bladder there are very apt to be simi 



812 DISEASES OF WOMEN". 

lar deposits in the kidneys and ureters, giving rise to destruction 
of the former and tubercular pyelitis in the latter. 

Symptomatology. — The symptoms are at first those of irrita- 
tion, and later of true cystitis, with ulceration, induration, and 
hypertrophy. 

Diagnosis. — The diagnosis may be made by means of the endo- 
scope, if there is opportunity to make early and repeated examina- 
tions. If by chance the deposits are located at the neck of the 
bladder, where they can be seen and watched going on to ulcera- 
tion, the diagnosis is not impossible. The history of the case 
and the presence of the tubercular diathesis will also aid in the 
final conclusions. The urine examined by the microscope is found 
to contain a granular matter mixed with the pus of cystitis which is 
sooner or later produced. In case the microscopist is fortunate in 
finding the baciUus tuberculosis the diagnosis is sure. 

Prognosis. — The prognosis is bad, as there usually exists serious 
trouble of the same nature elsewhere, and as local treatment accom- 
plishes very little, the end comes much sooner if the kidneys and 
ureters are involved in the disease. 

Treatment. — Local treatment is out of the question, except such 
as may allay the irritation or infl.ammation to a certain extent, and 
prevent undue pain and spasm. This is not readily done. Daily 
cleansing of the viscus with warm water; opium, and belladonna 
suppositories, or enemata of atropine, are the best methods of treat- 
ment. 

Warmth, attention to diet, general tonics, cod-liver oil, and the 
various remedies used in phthisis pulmonalis should be advised. 

Malignant Growths. — These are not common, although occurring 
more often than the benign growths. They are usually secondary, 
and may be of different varieties, as sarcoma, scirrhus, encephaloid, 
epithelial, villous, and even colloid cancer. Sarcoma, scirrhus, 
colloid, and epithelial are very rare ; encephaloid and villous are 
more common. 

Symptomatology. — The symptoms are the same as those of the 
benign tumors, differing only in the greater extent and severity of 
the pain, and, as a rule, less haemorrhage. The condition of the gen- 
eral system is usually low, the patient soon becoming feeble and 
cachectic. Cancerous deposits in the kidney and extension of the 
inflammation up the ureters, may produce renal destruction and 
consequent uraemia. 

Diagnosis. — The only means of making an absolute diagnosis is 
by using the endoscope, and removing a bit of the tumor with 



NON-INFLAMMATORY DISEASES OF THE BLADDER. 813 

the curette, and submitting it to a microscopical examination. 
Sarcoma and scirrhus may exist either as distinct tumors or as 
diffused indurations. The encephaloid variety usually grows rap- 
idly, and is very soft, and easily broken down. I have already said 
that cancer of neighboring organs may open into the bladder and 
produce most serious results, sooner or later involving the bladder- 
tissue in the destructive process. In any case, adhesion to the 
neighboring organs takes place, and the disease is liable to extend. 
Thrombosis of the veins of the vesical neck is apt to occur and lead 
to embolus elsewhere. Peritonitis is a frequent accompaniment. 

The favorite seat of cancer, especially of the villous form, is at 
the trigone. Some authors deny the existence of villous cancer, 
saying that it is simply a luxuriant growth of vesical papilloma, 
and base their opinion upon the nature of its structure and certain 
facts in its clinical history. " They never lead to secondary can- 
cerous deposits elsewhere. They do not spontaneously ulcerate. 
The lymphatic glands are not implicated. There is no characteristic 
cachexia. "When they kill, death seems due purely to loss of blood 
and exhaustion from pain." — Van Buren and Keyes^ p. 257. 

Most German authors claim that this growth is malignant, and 
think that in drawing deductions, such as I have given above, the 
observers saw only cases of simple non-ni align ant papilloma. 

Causation. — Nothing is known about the causes of malignant 
disease of the bladder, except that which is known about malignant 
disease elsewhere, consequently, that subject need not be discussed 
here. 

Treatment. — If the disease is not too far advanced, extirpation 
or breaking down of the tumor may be advisable, but except in the 
case of epithelioma, and the so-called villous cancer, but little good 
is to be hoped for. 

When removal is not advisable, we must look to narcotics and 
tonics to prolong the patient's life and relieve the intense pain and 
tenesmus. 

If the tumor is generally distributed throughout the bladder, or 
has its origin in a neighboring organ, extirpation is out of the 
question. 

Sarcomatous Tumor of the Bladder. ^Dr. L. A. Stimson, at a society 
meeting, exhibited a tumor of the bladder removed from a gentleman 
sixty-three years of age. When admitted to the Presbyterian Hos- 
pital in the early part of October, the patient complained of frequent 
and painful passage of bloody urine. His iirst attack occured in the 
eariy part of July, and two or three weeks after a fall from a buggy. 



814 DISEASES OF WOMEN. 

For the previous four years he gave a history of attacks of so-called 
bilious colic, which in connection with his bladder trouble gave rise 
to the suspicion, in the mind of Dr. Stimson, of renal colic, and the 
possible existence of vesical calculus. After unavailing efforts to 
reduce the irritability of the bladder the patient was sounded for 
stone with negative results. A subsequent examination was also of 
a negative character. The use of the searcher was followed each 
time by blood in the urine for two or three days consecutively. 
Examination j9^/^ rectum revealed enlargement of the prostate, and 
fulness and doughiness about the bladder, which condition was sup- 
posed to be due to cystitis. The existence of a tumor was suspected, 
but the suspicion could not be confirmed, inasmuch as the condition 
of the patient forbade bimanual exploration. Ruling out the prob- 
ability of the existence of a tumor of the bladder, pyelitis was 
thought of as a cause for his trouble. The patient died rather 
suddenly without a positive diagnosis having been made. At the 
autopsy, and before the body was opened, bimanual palpation was 
performed, and the existence of a tumor was made out. On open- 
ing the bladder the morbid growth, which proved to be a sarcoma, 
three inches in diameter, was attached by a pedicle as thick as the 
finger to the posterior surface of the bladder, about four inches 
above the neck of the organ. 



HYPERPLASIA. 

Hyperplasia of the bladder may be partial or total ; may be con- 
fined to the muscular, raucous, or connective tissue. In using the 
term hyperplasia reference is usually made to an increased thickness 
of the muscular walls alone. There usually coexists with this con- 
dition (which is partly hypertrophy, partly hyperplasia) increase in 
thickness of the various other structures of the organ. This may or 
may not be the case, and when existing it is more hyperplasia than 
hypertrophy. The terms partial and total have been used to convey 
the idea of hypertrophy of a part or parts of the muscular tissue, and 
do not usually refer to the number of coats involved. The truth is, 
however, that one part of the muscular tissue of the organ seldom 
becomes hypertrophied to any extent without involving the other 
parts ; the increase in one part simply being greater than in another. 

This affection is much less frequent in the female than in the 
male, owing to her exemption from the more common causes of it. 
Any obstruction to the outflow of urine, as tumors of the urethra 
or bladder, partly or wholly blocking the passage; cystocele, by 



NON-INFLAMMATORY DISEASES OF THE BLADDER. 815 

preventing complete evacuation ; inflammatory or nervous troubles, 
causing unusually active muscular contraction, continuing for some 
time ; all these may produce muscular hyperplasia. Inflammation 
of the mucous membrane is almost always present ; sooner or later, 
that membrane becomes to a certain extent thickened, and may go 
as far as the production of tufty, polypoid hyperplasia. Yan Buren 
and Keyes state that Civiale mentions hypertrophy, chiefly of the 
anterior vesical wall, due to chronic inflammation or tubercular in- 
filtration — evidently not simple hypertrophy. 

As the production of hypertrophy is almost always due to some 
obstruction to the outflow of the urine, dilatation after a time oc- 
curs, producing eccentric hyperplasia. When dilatation does not 
occur, but hyperplasia alone, the condition is produced which is 
known as concentric hyperplasia. In these cases of muscular hyper- 
trophy in which great force is required to expel the urine, pouches 
are sometimes formed, usually at the inferior fundus, caused by the 
pushing of the mucous membrane between the enlarged muscular 
fibers. These diverticula are comparatively rare in the female. A 
sagging or dislocation of the entire posterior inferior bladder-wall 
need not be discussed here, as it has been already disposed of. 

Symptomatology. — In concentric hyperplasia there is usually vesi- 
cal spasm, some pain, and forcible ejection of urine. A certain 
amount of cystitis almost always accompanies this affection, and 
surely aggravates the original disorder, by which it is itself further 
aggravated. In the eccentric form the symptoms are almost the 
same, there being sometimes superadded those of overdistention. 

Diagnosis. — This is readily made by introducing the finger into 
the vagina and the sound into the bladder, by which means the ca- 
pacity of the organ can be measured and the thickness of its walls 
ascertained. It is not unusual in the concentric form for the sound 
to be forcibly expelled from the bladder by a sudden contraction of 
that organ. The capacity of the viscus can be further measured by 
noting the amount of urine passed at each micturition, or by inject- 
ing into it some bland solution, such as salt and lukewarm water. 

Treatment. — The treatment must be directed to the removal of 
the cause when that is possible. If due to stricture of the urethra 
or the presence of tumors, their removal is to be considered ; if to 
cystocele, replacement, and retention in place by a proper pessary, 
and other measures of which I have spoken fully in a previous 
chapter, must be adopted. 

When existing in the eccentric form an abdominal belt, cold 
baths, cold douches to the hips, astringent injections into the blad- 



816 DISEASES OF WOMEN". 

der, and electricity, should be tried, having first, where possible, 
removed the cause, and palliated or cured the aggravating complica- 
tions. Daily catheterization, in cases of obstruction to the outflow 
of urine, or where, without obstruction there is liability to over- 
distention, is of great importance, and should be practiced. 



ATROPHY. 

So far as I know this is not a common disease. Its recognition 
during life being by no means easy, and but little attention being 
paid to the bladder in autopsies, very little knowledge of its fre- 
quency is had. I am inclined to believe, however, that it exists 
oftener than is commonly supposed. Its causes may be ranged 
under two heads, viz., constitutional and local. 

Constitutional. — In most women from fifty years of age upward 
a degenerative change takes place in the bladder, as in the other 
pelvic organs, and this is a perfectly natural process. In this con- 
dition the several coats are found proportionally changed, the three 
sometimes forming a wall not much thicker than fine writing-paper. 
This, however, is extreme and uncommon. The process causing 
atrophy is one of fatty and granular degeneration, and often at this 
age the epithelial cells of the bladder found in the urine are fatty 
and granular, as is also the case in both the vesical and vaginal epi- 
thehum of some women just after parturition. 

Walls thus thinned by the degenerative changes of age are of 
course much more liable to be still further altered by various causes, 
such as paralysis or overdistention. Winckel attributes the cysto- 
eele of aged women to atrophy of the bladder -walls, and the result- 
ing retention of urine. 

In soft, flabby and debilitated women, and also in men, an atro- 
phied condition of the bladder-walls often exists, and may lead to 
rupture. " Bonnet, Haul*, and Hunter (quoted by Pitha), give ex- 
amples of sudden rupture of the bladder in young persons from 
this cause (atrophy). Civiale gives the caution of avoiding pressure 
on the bladder- walls during catheterization, for fear of perforation." 
— Van Buren and Keyes. 

Local Causes. — Extreme distention of the bladder, leading to 
temporary or permanent paralysis, or paralysis with resulting over- 
distention, may lead to fatty degeneration and atrophy, as well as 
inflammatory trouble. Interrupted nutrition, due to shutting off 
the circulation, is the usual method of causation. JSTutritive changes 
may also be due to lack of, or to perverted, innervation caused by 



NON-INFLAMMATORY DISEASES OF THE BLADDER. 817 

disease or injuries of tlie spinal cord. When atrophy occurs in 
women under fifty years of age, who are in otherwise good health, 
and of good constitution, I believe that it is due to habitual over- 
distention of the bladder from retention of urine. 

Treatment — Daily use of the catheter, strychnia in pretty full 
doses, electricity, building up of the general system, and gentle 
washing out of the organ mth warm medicated solutions, may be 
tried. But little can be done when the degeneration is due to age. 

Atrophy of the Bladder from the Habit of retaining the Urine for 
a Long Time. — The lady was thirty-three years of age, large, and 
well developed, except that her heart and arteries were rather small. 
Her uterus was also undersized. She began to menstruate at fifteen 
years of age, and her menses were irregular in recurrence and dura- 
tion, and always attended with pain. Early in life she became a 
school-teacher, and had followed that profession up to the time that 
I saw her. She fell into the habit of retaining her urine for long 
periods, and for several years urinated only twice in each twenty- 
four hours. For some time she had noticed a growing difficulty in 
emptying her bladder, and five months before consulting me she 
found that she had lost the power of urinating altogether. Her 
physician used the catheter regularly for a time, and then taught 
her to use it herself. Under this treatment, with tonics and seda- 
tives, she gradually regained a partial control of her bladder ; but 
with it came an irritable condition of that organ and the urethra, 
which caused an almost constant desire to urinate. 

When I examined her I found slight prolapsus of the base of the 
bladder, and, by passing a sound into it, and a finger in the vagina, 
I found the posterior bladder-wall quite thin. There were also in- 
dications of a slight catarrh of the organ, doubtless brought on by 
the continued overdistention and prolonged use of the catheter. She 
told me that she had to make strong efforts to pass urine, and that 
it came away in interrupted jets. 

My impression of this case is, that her constant neglect of the 
bladder function caused overdistention, which led to atrophy and 
further distention. The use of the catheter permitted the organ to 
partially regain its muscular power, and also excited some catarrh. 
Passing the urine in spurts or jets was due, I presume, to the volun- 
tary muscular efforts. 



CHAPTER XLYI. 

DISEASES OF THE UKETHRA AND UEETHKAL GLANDS. 

Having finislied tlie consideration of tlie diseases whicli affect 
tlie bladder, I now invite attention to those whicli affect tlie ure- 
thra and its glands. These may be divided into two classes : 

I. Functional diseases. 

II. Organic diseases. 



I. FUNCTIONAL DISEASES OF THE URETHRA. 

I know of but one form of affection which properly comes under 
this head, and that is commonly denominated neuralgia. A case will 
be occasionally met in which there are pain and tenderness of the 
urethra, with frequent desire to urinate, and pain in doing so. In 
short, there is a history of subacute urethritis ; but, upon the most 
careful examination that can be made, with all the means at one's 
command, there will be failure to find any lesions to account for the 
symptoms present. To this condition the name neuralgia has been 
applied, rather improperly, no doubt. From my own observation of 
this affection, in which there are well-marked symptoms, with no 
apparent anatomical lesions, I have been led to the conclusion that 
it is a disease of the nerves of the part — one of the neuroses, as they 
are called. It is quite possible, however, that progress in the diag- 
nosis of urethral diseases may yet enable diagnosticians to find lesions 
other than of the nerves to account for the symptoms presented by 
the disease in question. But for the present it must be classed 
among the neuroses. 

So far as I know, it is an affection peculiar to young women. I 
have only seen it among young married women of marked nervous 
temperament, and who have not borne children. In some of the 
cases observed, it was associated with an irritable condition of the 
introitus vulvse. 



DISEASES OF THE URETHRA AND URETHRAL GLANDS. 819 

The symptoms are such as occur in a great variety of pathologi- 
cal conditions, and are, therefore, of little value in guiding to a cor- 
rect idea of the real trouble ; and, as there are no diagnostic physical 
signs present, the diagnosis must be made by exclusion. The most 
thorough examination of the urine should be made, and the urethra 
and neighboring organs should be carefully investigated. Perhaps 
the greatest liability to error' lies in mistaking this condition for 
reflex irritation of the urethra and bladder, arising from ovarian, 
uterine, or rectal disease. Careful inquiry into the condition of 
those organs should therefore be made before concluding that the 
disease is of the urethra itself. 

The affection is fortunately rare as well as obscure. I will, there- 
fore, relate the history of some cases, which will give the facts as 
they were observed clinically. 

ILLUSTRATIVE CASES. 

One case was that of a lady of a highly nervous temperament, 
whose parents died of tuberculosis. She was twenty- six years of age, 
and had been married three years. From the time of her marriage 
she began to suffer from painful menstruation and uterine leucor- 
rhoea. She attributed her trouble to getting cold while driving in 
an open carriage behind a fast horse. She had an anteflexion of the 
uterus and cervical endometritis. The right ovary was large, tender, 
and prolapsed. Before, during, and after her menses she had smart- 
ing and burning pain in the urethra, with a feeling of spasmodic 
contraction, wiiich sometimes rendered urination difficult and pain- 
ful. In the interval between the menstrual periods she had tender- 
ness of the urethra and discomfort in passing urine. 

The urethra was repeatedly examined throughout its whole extent 
with the endoscope, but no disease could be found, only tenderness 
and spasmodic action. 

She derived relief from suppositories of morphine and bella- 
donna, but, when last seen, she still had attacks of the same trouble. 
It was supposed, at flrst, that the urethral trouble was due to the 
disease of the uterus, but the former persisted after the latter was 
relieved. 

Another case was that of a lady, aged twenty-nine, who had been 
married for seven years, but had never been pregnant. She was of a 
highly nervous temperament, but her general health had always been 
good. She began to menstruate at fourteen years of age, and con- 
tinued to do so regularly, but scantily. For several years she had 
suffered from backache and slight uterine leucorrhcea. and coitus had 



820 DISEASES OF WOMEN. 

always been painful. She had frequent and painful urination. The 
uterus was small — in fact, all the reproductive organs were under- 
sized. There was marked tenderness of the introitus vulvae. The 
remains of the hymen were very tender, and at the meatus urinarius 
and on the vestibule there were a number of quite small papillomata 
(of the same color as the mucous membrane) that were also exceed- 
ingly tender. These were destroyed by an application of equal parts 
of carbolic acid and tincture of iodine, and the leucorrhoea was ar- 
rested by the usual treatment. This relieved her of ail the symptoms 
except those of the urinary organs. Her urine was examined repeat- 
edly, and was found to be normal. The urethra was also investi- 
gated, but nothing wrong was found there except that the papillae 
appeared to be unusually prominent. I learned that if she retained 
the urine for an hour or two the desire to urinate passed off, and 
did not return until the bladder was fully distended. When she did 
urinate, the desire to empty the bladder continued — i. e., she had 
vesical tenesmus — but, if she indulged this feeling by passing the 
urine repeatedly, this tenesmus continued ; while, if she resisted the 
desire, it gradually subsided. This proved conclusively that the 
cause of the frequent urination was the condition of the urethra. 

Quite a variety of agents, which I need not give in detail here, 
were tried in this case. Suffice it to say that she only derived bene- 
fit from coating the entire mucous membrane of the urethra with 
dry subnitrate of bismuth once a day for a week, and then applying 
equal parts of tincture of aconite and aqueous extract of opium 
twice a week for a time. The bismuth was made into an emulsion 
with water and a little acacia, and applied with the pipette. A steel 
sound was also passed once a week, and allowed to remain in place 
for about five minutes. This gave pain at the time, but relief fol- 
lowed. During the local treatment she took nourishing food, iron, 
and arsenic. She may be said to have recovered ; but overtaxation, 
mental or physical, would bring back the trouble in a slight degree 
for a short time. 



II. ORGANIC DISEASES OF THE URETHRA. 

This class may be subdivided into ten groups. 

1. Inflammation or urethritis. 

2. Granular erosion. 

3. Yesico-urethral fissure. 

4. Neoplasms. 

5. Dilatation. 



ORGANIC DISEASES OF THE URETHRA. 821 

6. Dislocation. 

Y. Prolapsus. 

8. Stricture. 

9. Foreign bodies. 
10. Fistula. 

1. Inflammation of the Urethra, or Urethritis. — This is of three 
varieties {a) acute, {h) chronic, and {c) gonorrhoeal. 

Acute urethritis, though not a very frequent disease among 
women, is a very distressing one, and often difficult to relieve. In 
many cases it will be found to depend upon a speciiic cause, that is, 
gonorrhoea ; and I would treat this subject as- gonorrhoea in women, 
were it not that it is often difficult to tell a specific or venereal ure- 
thritis from simple inflammation of that portion of mucous mem- 
brane. There is a difference in the history when correct testimony 
is obtained from the patient. Simple urethritis usually comes on 
gradually, and is often preceded by symptoms of uterine or vesical 
disease ; while the gonorrhoeal variety comes on rather abruptly, and 
is preceded or attended by acute vaginitis and vulvitis. The chief 
symptom in both varieties is painful urination. Sharp scalding is 
produced by the urine passing over the tender surface. There is 
often a frequent desire to urinate, but not so urgent as in cystitis. In 
some cases the urine is retained for a long time, evidently from a 
dread of the pain caused in passing it. 

In quite a number of cases I have noticed hseraorrhage. That 
the blood comes from the urethra is known by the fact that it is not 
intimately mixed with the urine ; and after micturition it will ooze 
from the meatus urinarius. 

An examination of the parts will show signs of inflammation 
about the meatus, with or without the same condition of the vulva. 
Occasionally, there is a discharge seen coming from the urethra, but 
if the parts have been recently bathed this may not be apparent. 
Introducing the finger into the vagina, and pressing upon the urethra 
from above downward, the discharge can be started, unless the pa- 
tient has passed water immediately before. The appearance of the 
discharge corresponds to that of gonorrhoea in its various stages. 
An examination of the discharge with the microscope may reveal 
the presence of the gonococcus, and, if so, that will determine the 
nature of the urethritis. The absence of that germ is not positive 
proof that the inflammation is not gonorrhoeal, unless frequent and 
skilled examinations fail to find it. 

Cystitis, which is liable to be confounded with urethritis, may be 
excluded by using the catheter, and after letting urine flow for a 



822 DISEASES OF WOMEN. 

time, collecting the remainder for examination. The mucous mem- 
brane, as seen through the endoscope, is of a deep red, with pus or 
mucus lodged in its folds. The instrument can not be used in all 
cases, owing to the acute tenderness of the parts. Bleeding is very 
likely to occur at the examination, simply from the contact of the 
endoscope. 

The treatment of acute urethritis, whether specific or not, may be 
conducted on the same principles as that of gonorrhoea in the male, 
usino- the same constitutional remedies, local baths, etc. This will 
suffice in most cases of acute disease ; but when it assumes the sub- 
acute form from the beginning, then the use of injections becomes 
necessary. 

Dr. Avery Segur, of Brooklyn, finds that the discharge of gonor- 
rhoea is markedly lessened, and sometimes cured, by ten-grain doses 
of salicylic acid, given in solution several times a day. 

I have seen much benefit derived from douching the urethra 
with water as hot as the patient could bear it. For this purpose I 
use a catheter made like the fluted roller of a crimping-machine, the 
appearance of which is doubtless familiar. Fig. 240. Inside the cath- 




FiG. 240. — Skene's reflux catheter. 

eter there is a small supply-tube, which conveys the water to the 
rounded point of the instrument. Behind the point of the catheter, 
where the grooves terminate, there is a perforation in each groove 
through which the water returns. By this arrangement the water as 
it flows back through the grooves is brought in contact with every 
portion of the mucous membrane. The instrument is passed up to 
the neck of the bladder, and a fountain -syringe attached to it, and 
the water as it flows away is caught in a cup. 

The injection of solutions of nitrate of silver, sulphate of zinc, 
and the like, will often prove useful. It must be borne in mind that 
the female urethra will not hold more than ten or fifteen drops, and 
if more is used it will enter the bladder, even where but very slight 
force is employed while injecting. I use a large pipette, placing 
the nozzle over (not in) the meatus, and inject slowly and without 
force a small quantity. When the case is of long standing, and the 
neck of the bladder appears to be involved also, I use a mild injec- 
tion of one or two grains of nitrate of silver to the ounce, and inject 



ORGANIC DISEASES OF THE URETHRA. 823 

it through, the urethra with force enough to enter the bladder, and 
let it remain there, to be passed off when the patient urinates. In 
acute urethritis the most efficient treatment that I have found is to 
wash out the urethra with the reflux catheter two or three times a 
day, and then introduce a suppository of iodoform in cocoa-butter, or 
bismuth and cocoa-butter. In old cases, which, began by a severe 
acute attack, and where the walls of the urethra are very much 
thickened and the canal contracted, dilatation with bougies does 
much good. While the bougie is passed once or twice a wxek, I 
apply to the vaginal portion of the urethra oleate of mercury or the 
unguentum hydrargyri. This will often suffice to stop the gleety dis- 
charge, as well as remove the thickening of the urethral walls. The 
case reported by Dr. Howard, which will be found at the close of 
the consideration of the diseases affecting the urethral glands, would 
seem to indicate that a gonorrhoeal urethritis in which these glands 
are involved may continue indefinitely unless appropriate treatment 
is directed to them. 

Treatment of Chronic Urethritis and Spasm of the Bladder. — Dur- 
ing the past ten years Weiser has adopted a new method of treat- 
ment in chronic gonorrhoea, and out of twenty-five cases he has suc- 
ceeded in curing all but one. The latter was afterward advised to 
consult Dr. Greenfeld, who, by means of the endoscope, discovered 
granulations in the urethra, which being cauterized, the man got 
well after several weeks' treatment. Weiser first passes an elastic or 
metallic catheter into the bladder, and, after thoroughly evacuating 
the viscus, injects into it by means of a clysopompe, or, preferably, 
an irrigator, a solution of sulphate of zinc, 2 to 3, and tannin, 0*5 
in 500 of water, at a temperature of 26° R. The catheter is then 
withdrawn, and the patient directed to empty his bladder, thus bring- 
ing the medicated solution in thorough contact with the whole of the 
urethra. This method is effectual in all cases when no granulations 
exist. The latter require the application of caustics. 

The author has, however, omitted to state how long the treat- 
ment must be continued. In cases with associated cystitis three to 
four drops of nitrite of amyl should be added to the above solution, 
the former being a very active disinfectant — one or two drops added 
to a bottle of urine serving to prevent the development of ammonia 
in the latter for a couple of years. When strictures are present they 
should be treated with metallic sounds. For the relief of cysto- 
spasms, the above-mentioned solution may also be employed ; one or 
two injections a day, continued for an average period of three 
months, usually suffice to entirely cure this condition. Frictions 



824: DISEASES OF WOMEN. 

with cold water and lukewarm (26° R.) sitz-baths may be employed 
as adjuvants. — '' Mittheilungen des Wiener Med.^ Doctor en- Collegi- 
ums^ June 23, 1881 ; New York Medical Record, Octoher 1, 1881, 
p. 375, 

A Case of Chronic Urethritis treated by Emmet's Button-Hole 
Operation. (By Yirgil O. Hardon, M. D., Atlanta, Ga.) — E. J., white, 
widow, aged sixty-one, was married at thirteen, and has borne nine- 
teen children. All her labors were normal, as far as she knows, and 
her health had always been good until twelve years ago. She then 
began to suffer from frequent desire for micturition, and the act was 
always accompanied by burning pains. These symptoms gradually 
increased in severity, until at the present time she is obliged to uri- 
nate at intervals of from fifteen to thirty minutes throughout the day 
and night. The passage of urine produces an intense pain in the 
urethra, especially at the meatus, radiating upward into the abdomen 
and downward into the thighs. This pain persists for some time 
after micturition, so that she is hardly ever free from it. In other 
respects her health is good, but her naturally robust constitution is 
breaking down under the constant pain and annoyance to which she 
is subjected. She is entirely unfitted for social or domestic duties, 
and nearly her whole time and attention are given to keeping her 
bladder empty. 

Examination shows the meatus contracted so as to scarcely admit 
a ISTo. 6 sound, and surrounded by cicatricial tissue, forming bands 
by which it is much distorted. Extreme tenderness exists along the 
urethra and in the neck of the bladder. The passage of a sound 
gives exquisite pain. The urethro- vaginal septum is of abnormal 
thickness and density. Otherwise the pelvic organs are found to be 
normal. 

The urine, of which about an ounce is passed at a time, is straw- 
colored and slightly turbid. Upon standing there is formed a de- 
posit of about one fourth its bulk ; specific gravity, 1028. Chem- 
ical and microscopical examination shows it to be free from albu- 
men, sugar, pus, and mucus. The deposit is made up of amorphous 
urates. 

The patient has been treated by internal medication by compe- 
tent practitioners, but without receiving any apparent benefit. 

January 23, 1886, with the assistance of Drs. Bizzell and Wile, 
she was etherized, and Emmet's button-hole operation was per- 
formed. An incision was made through the urethro-vaginal sep- 
tum, commencing a quarter of an inch behind the meatus and ex- 
tending to a quarter of an inch from the neck of the bladder. 



ORGANIC DISEASES OF THE URETQRA. 825 

Through this opening the cut edge of the urethral mucous mem- 
brane was drawn, and stitched on all sides to the cut edge of the 
vaginal mucous membrane with carbolized silk sutures. Thus no 
surface was left uncovered to heal by granulation. The urethral 
mucous membrane was found to be so intensely congested as to pre- 
sent a deep purple color, and capillary oozing of blood from it was 
very free. The parts were smeared with vaseline, and the patient 
was afterward instructed to make the same application before each 
micturition. The wound healed satisfactorily, and the sutures were 
removed on the eighth day, leaving a permanent urethro-vaginal 
fistula. 

In the twenty-four hours following the operation the patient 
urinated five times, with only slight pain. After the second day 
she was entirely free from pain, and has continued so ever since. 
She urinates sometimes twice, usually only once, and occasionally 
not at all during the night, and from four to six times during the 
day. She frequently holds her urine for six hours without any dis- 
comfort. The urine passes entirely through the artificial opening. 
The pain at the meatus and the tenderness along the urethra have 
ceased, and the congestion of the urethral mucous membrane is now 
very slight. — Atlanta Medical and Surgical Journal. 

2. Granular Erosion. — This very troublesome affection of the 
urethra may result from urethritis, or may appear without any pre- 
vious disease. The mucous membrane is covered with young, im- 
perfectly developed epithelium ; the papillae are hypertrophied and 
extremely sensitive. This gives rise to the most excruciating pain 
during micturition, and generally keeps up a distressing tenesmus. 
This disease is, fortunately, not very common. Old people are most 
liable to suffer from it. The diagnosis is made from the history and 
appearance of the urethra. The treatment which is most reliable is 
cauterization of the whole surface. The milder washes and injec- 
tions do not accomplish much. Pure carbolic acid may be tried 
first, brushing it over the surface, and repeating it in eight or ten 
days. This is the least painful application, and answers in some 
cases. When it fails, a solution of nitrate of silver (one drachm to 
the ounce) should be used. In some cases it is desirable before 
using strong caustics to dilate the urethra, and then touch it with 
carbolic acid in a mild solution, say two per cent. 

Among the inflammatory affections of the female urethra are 
mild forms of congestion and irritation, that fall short of well- 
marked urethritis. Indeed, some of these attacks amount to little 
more than congestion or slight catarrh. In others, I have found 
54 



826 DISEASES OF WOMEN. 

circumscribed patches of the urethra inflamed, and tlie rest of the 
canal normaL 

There is little, if anything, in medical works on the subject of 
these mild yet troublesome affections, and I hope that a clear idea of 
the subject will be gained from the narration of some cases which 
have come under my observation. 

ILLUSTRATIVE CASES. 

A yonng, married lady had been nnder my care for dysmenor- 
rhoea caused by anteflexion. She had recovered sufficiently to be- 
lieve that she was well enough to go to a party and dance to excess, 
which she did, and canght cold on the way home. On the second 
day after I was called to see her, and found her with the usual 
symptoms of an ordinary cold, that caused her little anxiety. But 
she was suffering severely from frequent and painful micturition. 
I found slight general congestion of the uterus and vagina, and sus- 
pected cystitis, but the urine was normal. I then examined the 
urethra, and found it congested throughout, and with streaks of 
mucus lodged in the folds of the membrane. There was neither 
erosion nor ulceration. 

I directed her to rest quietly in bed, and drink freely of flaxseed- 
tea and spiritus setheris nitrosi. A suppository containing one 
quarter of a grain of extract of belladonna and a sixth of a grain of 
sulphate of morphia was directed to be introduced into the vagina 
at bed-time. Under this simple treatment she rapidly improved. 
Twelve days after the date of my visit she called to see me, and I 
then found that she could retain her urine for hours, but still had 
slight pain and burning during micturition. The urethra was again 
examined with the endoscope, and a few red patches found scat- 
tered here and there along the canal. This was all that remained of 
the trouble. Liquor bismuthi, sufficient in amount to fill the 
urethra, was injected every second day for a week, when she de- 
clared herself quite well. 

A second case was that of a young lady, healthy and active, who 
was head saleswoman in a department of a large dry -goods estab- 
lishment. During the holidays, from Christmas to New Year's, she 
was on her feet from eio-ht in the momino^ until ten or eleven at 
night. On the last day of the year she was seized with pain and 
burning in the urethra, and soon after she began to suffer from fre- 
quent and painful micturition. 

Three or four days after the attack I examined the urethra, and 
found several small ecchymoses at various parts of the mucous mem- 



ORGANIC DISEASES OF THE URETHRA. 827 

brane, the highest one being near the neck of the bladder. These 
spots were due to haemorrhages that had taken place into the mucous 
membrane, beneath the epithelial layer. The spots were dark, al- 
most black in the center, and surrounded by an inflamed border, 
which was bright red at the inner margin, but gradually shaded oft* 
into the natural color of the surrounding mucous membrane. 

My idea of the pathology of this case is that the congestion aris- 
ing from the maintenance of the erect position for so long a time 
caused some of the small vessels to rupture, and the hsemorrhage 
into the membrane produced little circumscribed spots of inflam- 
mation. 

She was directed to rest in the recumbent position, and drink 
freely of Yichy water. This she did, and made a good recovery ; 
but it was six or eight days before the pain in urinating left her 
entirely. 

It will be observed that these cases were both acute, and recov- 
ered very promptly ; and I could give several more histories which 
might lead to the supposition that such trivial ailments of the ure- 
thra are not of much importance after all. It might also be pre- 
sumed that this form of urethral disease would disappear in most 
cases without being treated. This is no doubt true, but they do 
not all recover spontaneously. Some of these mild cases tend to 
continue. They become chronic, and if neglected will continue for 
years, to the great annoyance of the subject. Of the chronic or 
continuous form of urethritis the following are good examples : A 
single woman, thirty years of age, had for ten years been occupied 
as dressmaker, and was in the habit of operating a sewing-machine 
occasionally. Her general health had always been excellent, but she 
consulted me for what she supposed to be an affection of the kid- 
neys. She said that for five years she had been annoyed with pain- 
ful and frequent micturition. She was obliged to urinate every two 
or three hours during the day, and several times in the night. 
Standing, walking, or exposure to cold invariably made her worse. 

An examination of her pelvic organs revealed slight catarrh of 
the cervix uteri, and a mild vaginitis, limited to the upper and pos- 
terior portion of the vagina, most marked behind the cervix. Her 
urine was examined carefully and found to be normal. The urethra 
was then examined by the endoscope, which brought to view a 
highly inflamed spot on the anterior wall of the urethra, and an in- 
flamed ulcer on the posterior wall. The disease w^as limited to the 
middle third of the urethra, and, wdiile extending all around, was 
most marked anteriorly and posteriorly. The ulcer, which lay in 



828 DISEASES OF WOMEN". 

the posterior wall or floor of the urethra, was superficial and appeared 
through the endoscope as a gray spot surrounded by a bright red 
areola. It bled on contact with or stretching by the instrument. 
The color of the upper and lower third of the urethra was somewhat 
darker than usual, but otherwise normal. 

The recovery in this case was somewhat tedious, because it was 
one of my first cases, and my treatment was experimental and not 
always beneficial. First, I touched the inflamed parts with a solu- 
tion of nitrate of silver (one drachm to the ounce), using just enough 
to whiten the surface. This gave her rather sharp pain, which 
passed off, however, in a few hours. After this she had much pain 
in passing water, but the frequency was about the same as before 
the application. About ten days after using the solution the parts, 
though still inflamed, were much improved. 

This advantage gained suggested a repetition of the application, 
which I made. It was followed by very severe pain, that lasted two 
days and nights before it subsided. There was no improvement. 
After this I injected into the urethra, twice a week, a solution con- 
sisting of 

;p Zinci sulphatis gr. iv. 

Fl. ext. hydrastis Canadensis 5 j- 

Aquae 5 iij. M. 

About half a drachm of this was used at a time. This was con- 
tinued for about a month with marked benefit. At the end of that 
time she could rest all night without urinating, and had to micturate 
only about every four hours during the day, and had very little pain. 
Injection of liquor bismuthi (half a drachm) was then begun, and 
continued twice a week for three weeks, when she was free from all 
trouble, but was obliged to urinate every four or six hours, from 
habit, I suppose. 

One other case may be given to show the disposition of this form 
of urethral trouble to continue. This patient was thirty-nine years 
of age, and had been a widow for sixteen years. Her only child was 
a grown-up woman. Four years before I saw her she had a catarrh 
of the bladder, for which she was treated by a skilled physician. 
She recovered from that after a time, the urine becoming normal, 
and the ability to retain it excellent. She continued, however, to 
have pain in passing urine, but as there was no discomfort at any 
other time she was satisfied to tolerate that. 

Being troubled mth constipation while traveling, she was taken 
with agonizing pain after defecation, continuing to suffer with it for 
several months. She then applied to me for relief. She stated that 



ORGANIC DISEASES OF THE URETHRA. 

tlie pain during micturition had been mucli worse since the develop- 
ment of the rectal pain. The rectum was examined with the endo- 
scope (the same instrument used in exploring the bladder and 
urethra, but of larger size), and a well-delined fissure detected. This 
explained the rectal symptoms, and it is fair to suppose that the 
urethral trouble was aggravated by it sympathetically. The lower 
third of the urethra was found to be inflamed, and in places eroded. 
The anal fissure was relieved by the usual operation, and the urethra 
was treated with applications of nitrate of silver (one grain to the 
ounce). Recovery was speedy and satisfactory. 

3. Vesico-TIretliral Fissure. — This affection holds an intermediate 
position between cystitis and urethritis, and in its symptomatology 
bears a marked resemblance to both, and I have therefore deferred 
its consideration until both these diseases have been treated. 1 am 
fully satisfied that it is often mistaken for inflammation of the blad- 
der or urethra. 

It is only within the last few years that this trouble has been 
brought to the notice of the profession, and hence there is very little 
in medical literature on the subject. This afliection has heretofore 
been called fissure of the neck of the bladder. Were I to name it 
according to its location, I should say vesico-urethral fissure, for its 
usual site is at the point of junction of the two. 

The lesion, as the name indicates, is a crack or fissure of the 
mucous membrane, produced by ulceration. It runs lengthwise of 
the urethra, and is situated in one of the sulci or folds of the mem- 
brane formed by the corrugations which always exist when the 
urethra is not distended. It is usually spoken of as situated in the 
vesical neck, but as a rule two thirds of it is situated in the urethra, 
the upper end of it only extending into the bladder. 

It may occur at any part of the circumference of the urethra. 
In the majority of the cases that I have examined it has been situ- 
ated on the right side anteriorly. Those who are familial' with fis- 
sure of the rectum will understand that fissure of the vesical neck 
is exactly the same in appearance, save that it is much smaller. It 
is from a quarter to three eighths of an inch in length, and from one 
twelfth to one sixth of an inch in width at the center, but tapering 
off at each end. 

The deepest part has a yellowish gray color, like that of an in- 
dolent ulcer, while the edges are red and actually inflamed, like 
those of an irritable ulcer. When seen through a large endoscope 
that puts the parts upon the stretch, it may appear freshly torn and 
bleeding. The edges are usually abrupt, elevated, and indurated, 



880 DISEASES OF WOMEK 

and of a dark or bright red color. This shades off gradually into 
the normal membrane of the urethra. 

The importance of this lesion depends upon its site. An ulcer 
or fissure of the same size, if situated in any other portion of the 
urethra, would cause little suffering beyond a smarting sensation 
during micturition. But occurring at the union of the bladder and 
urethra it is submitted to constant though slight pressure, which 
causes severe and continuous pain. I believe that the very great 
suffering caused by this disease is due largely to the fact that these 
parts of the bladder and urethra are by far the most sensitive, and 
that the upper portion of the fissure, which extends into the bladder, 
is exposed to the irritation of the urine, which excites the constant 
desire to urinate. The pain which is thus produced causes exces- 
sive contraction of the urethra and bladder, and this contraction 
again causes pain, " the vicious circle," as it is termed, being thus 
established. In other words, the cause produces an effect, which 
in turn, acts as a cause and aggravates the original disorder. 

Symptomatology. — The symptoms of fissure are a constant desire 
to urinate, and a feehng of burning pain at the neck of the bladder. 
There is acute pain both during and immediately after the act of 
micturition, and severe tenesmus, which causes the patient to make 
voluntary straining efforts at evacuation after the bladder is empty. 
Immediately after urination the pain and burning are often intense. 
After a time it partially subsides, but again commences when a lit- 
tle urine collects in the bladder. 

When the patients resist the desire to urinate (as they often do 
at night when unwilling to get up) the distress is much aggravated. 
It will be seen that all the symptoms mentioned are much the same 
as those presented in cystitis, and on that account are not reliable 
guides in diagnosis. Urethritis also gives rise to many of the symp- 
toms named above, and might be mistaken for urethro- vesical fissure. 
There are, however, some points of difference between the symptoms 
of these three affections that are deserving of notice. In fissure the 
pain is, as a rule, more circumscribed than in either cystitis or ure- 
thritis, and in many cases more acute. Urination in fissure is 
always followed by the maximum of pain, while in cystitis there is 
a slight sense of relief. In urethritis the greatest pain is experi- 
enced during the act of urination ; it then subsides gradually, and is 
usually absent before the next evacuation of the bladder. 

Diagnosis. — The question of diagnosis will usually rest between 
fissure, urethritis, and cystitis. The latter can be easily and posi- 
tively excluded by an examination of the urine. Passing a catheter 



ORGAmC DISEASES OF THE UKETHRA. 831 

into the bladder and allowing a little urine to flow tlirongh it will 
wash awaj any pus or mucus that may have been caught up in its 
introduction. The remaining urine should be saved for examina- 
tion, when if fissure alone exist, it will be found free from all the 
products of cystitis. 

The exclusion of urethritis and the detection of fissure are ac- 
complished by the endoscope, and by the use of this instrument a 
correct diagnosis can easily be made. I have already described the 
method of using my endoscope, but there are a few points in the 
examination for fissure to which I have yet to call attention. In 
the first place, the neck of the bladder must be found exactly, and 
to accomplish this the instrument must be used when there is at 
least a small quantity of urine in the organ. Then the tube is to be 
introduced far enough to be sure that it enters the bladder. Next 
the mirror is to be passed in, and, when it enters that part of the 
tube surrounded by urine, it will be seen that it becomes black, i. e., 
the wall of the urethra (which was reflected as the mirror was passed 
in) disappears, and nothing can be seen. By slowly withdrawing 
the mirror the upper end of the urethra will come into view, and 
by moving it backward and forward and turning it round, the whole 
circumference of the vesico-urethral juncture can be clearly seen, 
and the fissure distinctly observed. 

The service rendered me by this instrument in studying this 
affection has been very great. Indeed, I was never able to detect a 
vesico-urethral fissure until I used this endoscope to look for it. I 
have tried repeatedly to find a fissure with the ordinary open-tube 
endoscope, and have invariably failed, and for these reasons : Fissure 
lies in a longitudinal sulcus of the mucous membrane, and is hidden 
from view at the upper or open end of the tube. It can only be 
brought to light by distending the urethra at the point to be ob- 
served, and that can not be done with the instrument in question. 
Again, when the open tube is carried up to the neck of the bladder, 
where the fissure is situated, the urine flows into the tube and puts 
a stop to observations. 

The description of the appearance of fissure already given was 
taken from my own observation with the endoscope, and, therefore, 
need not be repeated here. 

Causation. — The cause or causes of fissure here are not well 
understood. At least, I have not been able to find anything in the 
books that is clear and definite on tlie subject. 

From a careful study of the cases which have come under my 
own observation, I am satisfied that fissure (or irritable ulcer) is 



832 DISEASES OF WOMEJT. 

developed from urethritis. I will suppose that a woman gets 
urethritis, from any cause, and that it extends to the neck of the 
bladder, and dips down into the folds of the mucous membrane. It 
is easy to understand that the pressing together of the two inflamed 
surfaces of the membrane in these folds will increase the irritation 
and keep up the disease. Urine, mucus, pus, and exfoliated epithe- 
lium are liable to lodge in this location, and add very much to the 
irritation. All this leads to ulceration, and when this is estabhshed 
it remains, with no tendency to recover. Even if the parts were 
inclined to heal, the irritation of the urine and inflammatory prod- 
ucts, as well as the contraction of the inflamed surfaces upon each 
other, would prevent, or at least hinder, recovery. 

It can be seen that an m-ethritis might end promptly in recovery 
(either by the natural tendency of mucous inflammation to return to 
health, or under the influence of treatment), except at the point of 
fissure, where the conditions named tend to produce ulceration, and 
when once developed, to keep it up. 

Injuries during confinement, displacements of the bladder, indeed, 
injuries of any kind that are sufiQcient to cause inflammation at the 
vesico-urethral juncture, doubtless tend to the establishment of 
fissure. 

Bungling or careless use of the catheter, or injections into the 
bladder or urethra, might have the same evil effects. 

I suspect, but am not quite sure, that very small calculi passing 
along the urethra may be a cause of this trouble. This supposition 
is based on a case which occurred in my practice. Its history is 
this. The lady had a vesico- vaginal fistula, and after it was closed 
she had catarrh of the bladder. During the course of that disease 
she was taken with haemorrhage, which lasted some days. She then 
had violent pain in urinating, and passed several lumps which were 
composed of mucus and some of the salts of the urine. These pieces 
were rough, gritty masses, which no doubt scratched the urethra as 
they passed out. Soon after this she was found to have a fissure 
that tormented her to an extent beyond description. Dilatation of 
the urethra and topical apphcations relieved her. 

Treatment, — The subject of the management of vesico-urethral 
fissure is one of interest and importance, as much so as anything in 
surgery. On the one hand there is the terrible suffering of the 
patient, and on the other there are many difficulties to be encoun- 
tered in the efforts to relieve her. The demand for treatment is 
urgent, and skill in the highest degree is necessary to accomplish a 
cure. 



ORGANIC DlSExVSES OF THE URETHRA. 833 

I must first sav wliat ought not to be done in these cases, and 
thereby guard against making them worse instead of better, as it has 
been my misfortune to do on more than one occasion. As a rule, 
all injections and instillations such as I have recommended in cys- 
titis, and shall advise in urethritis, do harm in fissure. I have used 
injections of mild solutions of nitrate of silver, and the application 
of stronger solutions to the diseased part, with the invariable result 
of increasing the spasmodic contraction of the bladder and aggrava- 
ting the suffering of my patients. 

While such appHcations are useful in inflammation of the bladder 
and urethra they do harm in Assure. This I have repeatedly proved 
to my own satisfaction, and the facts accord with our experience in 
other departments of practice. ^Titrate of silver and nitric acid have 
been applied to ulcerations of the rectum with marked benefit, and 
without being followed by pain of any account ; but the same appli- 
cation made to fissure within the grasp of the sphincter ani does 
little if any good, and usually increases the suffering of the patient. 
The same is true of the fissure under discussion. When a diagnosis 
of vesico-urethral fissure has been made, the usual local treatment is 
not to be employed, at least active measures in the way of powerful 
applications are to be avoided. 

Soothing applications, alterative in their action, are worthy of 
trial. Exposing the fissure with the fenestrated speculum, and 
dusting it over with calomel or finely pulverized iodoform, some- 
times give relief. Subnitrate of bismuth may be used in the same 
way in the hope of doing good. There is one great point to be 
remembered in using these remedies, and that is, that if they fail to 
accomplish the desired end, they do no harm. 

I have used with benefit the "mitigated" stick of nitrate of 
silver. It consists of one part of nitrate of silver to two or three 
parts of the nitrate of potash. Drawing a fine point of this through 
the fissure causes sharp pain at the time, which is often followed by 
burning, and tenesmus, which, however, soon subside. In some 
cases the trouble is relieved by this treatment. 

Incising the fissure, in the manner that surgeons treat the same 
disease of the anus, 
lias been followed by 
great reliefj but I do 
not believe that I ever 
cured a case in this 




Fig. 2-11. — Skene's fissure probe and knift 



way. For this operation I use a small knife, which is represented 



in Fig. 211. 

o 



834: DISEASES OF WOMEN. 

In the employment of this local treatment great difficulty will be 
found in getting at the diseased spot. The fissure can easily be seen 
through the glass tube of the endoscope, but to expose it and make 
applications to it are exceedingly difficult tasks. I have tried in a 
variety of ways to do this, but have found that the only satisfactory 
way is by means of the endoscope, consisting of a glass tube, hard- 
rubber external tube, and mirror, which I have fully described. This 
combination of speculum and mirror answers very well in applying 
such remedies as bismuth, calomel, and the like ; but it will be found 
that skill and patience are required to touch the fissure with the 
nitrate-of-silver stick, or to incise the part as already advised. 

The method which I employ is this : A small silver probe is bent 
into the shape shown in the figure (Fig. 241), and its point is coated 
with the material to be used. It is then introduced through the 
speculum and drawn slowly through the fissure so as to produce 
superficial cauterization of the ulcerated part. The point of the 
probe is coated by melting the '' mitigated " stick of nitrate of silver 
in a platinum cup, into which the probe is dipped and the coating 
allowed to cool. The dipping may be repeated as often as is neces- 
sary to get the required amount of caustic or coating on the probe. 

Before applying the caustic, any mucus or serum that may be in 
or about the fissure must be sponged away. This may be done by 
wrapping a piece of absorbent cotton on the end of a probe, and 
using it as a sponge. 

It will be observed that I condemned caustics in the treatment 
of fissure, and still advise cauterizing the diseased part with nitrate 
of silver. The point is simply this, that caustics applied by injec- 
tion to the neck of the bladder in which there is fissure do harm, 
but caustic apphed to the fissure only, does good. 

I have observed that pain follows the application of caustics, but 
if the diseased portion and nothing more is thoroughly touched, re- 
lief follows. The old trouble and pain are, however, liable to return 
in time. The same may be said of incision, viz., that relief is but 
temporary. I think that the bleeding which is caused relieves irri- 
tation and congestion for a time, but I can not say that I have ever 
seen a permanent . cure follow this treatment, except in a few cases, 
where the treatment was begun early in the course of the disease. 

I come now to dilatation of the urethra as a means of relieving 
fissure. Although I have left this measure until the last, it is really 
the first in importance in the treatment of this affection. Indeed, 
I am inclined to think that it is of much more value in the treat- 
ment of fissure than in that of either cystitis or urethritis. 



ORGANIC DISEASES OF THE URETHRA. 835 

I Lave already sounded a note of warning against the two great 
dangers of dilating the nrethra — viz., rupture and incontinence, and 
incontinence without rupture. Both accidents are liable to occur in 
dilating the uretlira, but they only occur w^hen the dilatation is 
carried to a great extent, sufficient at least, to admit the ordinary 
sized index-finger. This extreme dilatation is not necessary in the 
treatment of fissure. I generally ascertain what sized sound can be 
passed with ease, and then dilate sufficiently to admit one three 
or four sizes larger. This is usually all that is necessary. 

Before dilating it must be seen that the urine is normal in char- 
acter, or as nearly so as can be made by general treatment. Then 
the urethra is to be dilated, the patient being kept at rest, and the 
urine made as bland as possible with diluent drinks. 

In case that incontinence should follow (though I presume that 
will not occur), its treatment should at once be commenced by sup- 
porting the urethra in the way that I have advised, viz., with the 
pessary for that purpose. I believe that, if taken in hand within 
three or four days after it occurs, the incontinence can be relieved. 

Should the treatment that I have thus far recommended fail, 
then a vesico- vaginal fistula should be made, the bladder and urethra 
washed out regularly, and if need be medicated. The fistula may 
be allowed to close of its own accord, as it usually will do. By the 
time the fistula closes, the fissure w^ill have healed. In making a 
vesico- vaginal fistula to cure fissure, the knife or scissors should be 
used, and not the cautery ; because it is not necessary to maintain 
the opening in the bladder for a very long time ; and if it closes of 
its own accord, a very important operation is avoided. 

4. Neoplasms of the Urethra. — A knowledge of urethral neo- 
plasms is by no means confined to recent times, but up to a late 
date they have not been studied as closely as they deserve to be, nor 
classified in a comprehensive and scientific manner. The various 
tumors have frequently been confounded with one another by 
authors and observers, and much confusion and obscure statement 
have resulted in regard to their symptomatology, pathology, and 
treatment. 

These growths have been variously known as carunculge, eellulo- 
vascular tumors, fleshy and vascular growths, fungoid excrescences, 
strawberry and raspberry tumors, each name sometimes having 
been used to cover the whole class. 

Winckel's division and classification are most excellent, and to 
some extent I shall follow them in the consideration of the subject. 
I will classify these tumors as follows : 



836 DISEASES OF WOMEX. 

Pajpillary. — Condjloraa. 

Glandular. — Cysts, mjxo-adenoma, mucous polypi. 

Vascular. — Angioma, varices, phlebectases. 

Areolar Connective Tissue. — Fibroma, sarcoma. 

Eintlielial . — Epithelioma, carcinoma. 

Cojnpound. — Papillary polypoid angioma, erectile tnmors. 

Neoplasms of the urethra are more common in the female than 
in the male, and, of course, easier of diagnosis and treatment. 

Papillary Neoplasms. — Under the first head, or that of papillary 
neoplasms, will be seen condyloma, a growth of a low grade, and of 
a warty appearance. The surface may be bright red, or partially 
white, from epithelial aggregation. These growths are painless, and 
do not bleed on touch or manipulation. They may or may not be 
pedunculated. They may occur singly or in clusters, and be wholly 
within the urethra or projecting from the meatus. 

They consist of somewhat dilated capillaries set in a tough homo- 
geneous network of connective tissue, the whole having a thin epi- 
thelial covering, that may at times be increased by an unusually 
rapid epithelial proliferation. This only occurs when the tumors 
are much irritated. 

Glandular Neoplasms, — Cysts of the female urethra are not com- 
mon, and are not confined to any period of life, having been found 
in a foetus of from six to seven months and in all subsequent periods 
of life. 

They are in early age situated in the anterior or meatal portion 
of the urethra, but later in life nearer the vesical neck. They may 
or may not project from the urethra ; however, they cause a greater 
or less obstruction to the free outflow of urine. They are usually 
formed by the occlusion of the orifice of the small urethral ducts 
or glands, and, in some cases, a black speck upon the surface of the 
cyst indicates the seat of the former orifice. 

By bagging of the mucous membrane and absorption of the con- 
tents, these small cysts may be transformed into polypi. 

Winckel says that the internal wall of the cyst usually shows 
numerous small papillge, and is lined with pavement epithehal scales. 

Myxo-adenoma are quite rare. They are small (the largest being 
seldom larger than a small hazel-nut), of a bright scarlet color, and 
quite vascular. They consist of a number of vessels set in partly 
destroyed gland tissue, and small meshes containing myxomatous 
matter. The whole is contained in the meshes of a soft, loose con- 
nective tissue. 

Polypi coming under this head are those formed by occlusion of 



ORGANIC DISEASES OF THE URETHRA. 837 

tlie orifices of one or more of the ducts or follicles of the urethra. 
The other forms of polypi will be considered under their proper 
head. 

Vascular Neoplasms. — Angioma, varices, and phlebectases are 
really different names for about the same condition — viz., an increase 
in the cahber of the veins and venous radicles, allowing an overdis- 
tention, at first intermittent, and later chronic. They appear as 
bunches or bundles of worm-like, irregularly distended dark blue 
or bluish red vessels. There is more or less thickening of the mucous 
membrane and connective tissue about them ; they are, in fact, in 
all respects analogous to rectal haemorrhoids. They may occupy any 
part of the urethra, but usually select the floor of the canal. The 
trouble they cause depends on their size. If large, they obstruct the 
urethra. Sometimes the vessels rupture, and the blood is poured out 
beneath the mucous membrane. Tumors resulting from rupture of 
such varices under a normal mucous membrane have been known to 
some authors under the name of hsematoma polyposum urethrse, 
which describes very well the condition resulting. 

Some of these vascular tumors have been found to be erectile, 
the anatomical peculiarities of which structure are already familiar. 

Yirchow believes these tumors to be a combination of urethral 
haemorrhoids and remnants of embryonal duplicity of the vagina. 

Areolar Neoplasms. — These new growths are either fibromata or 
sarcomata. 

The fibromata may lie within the canal of the urethra or be im- 
bedded in its walls. When in the urethra or protruding from the 
meatus, they are pedunculated, and have been known as uretliral 
polypi. They vary in size from that of a pea to that of a goose-egg. 
They consist of numerous densely packed fibers, that give the same 
appearances as fibromata elsewhere. 

They have been found in several cases at birth, but are of rare 
occurrence at any age. When congenital, they have been known as 
congenital polypoid excrescences. The tumors are usually covered 
with several layers of pavement epithelium. 

Sarcoma of the urethra is an extremely rare affection, but one or 
two cases being on record. One case observed by Beigel is described 
by Winckel. It was trilobed, about the size of a walnut, and was 
situated about the edge of the external meatus. It was in part hard, 
in part soft, the harder portion consisting of a fine fibrous network, 
tlie interstices of which were filled with small cells. In some places 
the cells were absent and the stroma more dense, and in the pe- 
ripheral parts the network, while coarser, was firm, and presented 



838 DISEASES OF WOMEN. 

cavities filled with a colloid material. The tumor was extirpated, 
but nothing is said about its return. 

Epithelial Neoplasms. — The existence of cancerous disease of the 
female urethra as a primary affection is greatly doubted by many 
authors, but it probably does occasionally occur. Indeed, as a sec- 
ondary disease, it is quite rare, for, when extending from the uterus 
or neighboring organs to the bladder, death, as a rule, results before 
the urethra is involved. In cases where life is unusually prolonged, 
the disease seldom attacks more than the vesical portion of the canal. 

Extension from the outer genitals, which are very rarely affected 
with cancerous disease, is still more uncommon, and possibly has 
never occurred. One case is recorded, however, in a woman who 
had long suffered from uterine prolapse, where a tumor, which de- 
pended from the frseniculum clitoridis, had invaded the meatus 
urinarius. Under the microscope it proved to be a flat-celled epi- 
thelio-cancroid. 

We have the record of cases of periurethral cancer that ap- 
paared at the introitus vulvae near the meatus, and in the connective 
tissue about the urethra, as small, hard, painless tubercles, the ure- 
thra or its membrane not being involved. 

Sym'ptomatology , — Pain is the exception rather than the rule in 
this affection ; but in some instances acute, lancinating pains are pres- 
ent. At first the tubercles are small, hard, and usually painless, but 
after a time they soften, ulcerate, and bleed freely. The vesti- 
bule and urethral mucous membrane are usually involved in the 
mischief. 

The affection has been divided into three grades, in the first of 
which, according to Winckel, "but half the length and depth of the 
urethra* is invaded by the cancerous tubercles ; in the second the 
vesical neck and pelvic fascia; and in the third the pubic sym- 
physis, descending pubic rami, and the closely blended connective 
tissue are involved." 

Compound Neoplasms. — The most common, and consequently the 
most interesting form of urethral neoplasm, is the papillary polypoid 
angioma. 

These tumors vary in size from a pin-head to a hickory-nut, and 
may be either multiple or single, but are usually single. They vary 
in color from a pale to a bright red, and may or may not be pedun- 
culated. Their favorite seat is on the posterior wall of the lower 
liaK of the urethi-a, very near to or at the meatus. This neoplasm 
is generally known as urethral caruncle, or vascular tumor of the 
urethra, and is described very fully in most of the books on diseases 



ORGANIC DISEASES OF THE URETHRA. 839 

of women. Indeed, it is the only abnormal growth of the female 
urethra that I ever read or heard of in my student days. There is 
really not much difference between this form of neoplasm and the 
vascular tumor of the urethra already described, and what is far more 
important both of these neoplasms have been confounded with hyper- 
plasia of the tissues around the mouths of the ducts of the urethral 
glands. This condition will be discussed under the head of diseases 
of the urethral glands. There are very good reasons why this affection 
should have claimed early attention from gynecologists. It occurs 
frequently, and nearly always causes great suffering, and is easily 
detected, because it grows at the meatus urinarius, where it can be 
seen. 

It consists of bunches of dilated capillaries set in a moderately 
dense stroma of connective tissue, and covered with mucous mem- 
brane, which has the usual pavement epithelium. One case, however, 
is recorded where the pavement was replaced by columnar epithe- 
lium. The vessels are greatly dilated, and in some cases very tor- 
tuous ; in others much less so. 

In some cases these tumors partake of the erectile character, 
being markedly increased in size at the menstrual period, and at 
other times. 

Occasionally small tumors of this kind are found singly in the 
vestibule. As a rule they bleed very easily on touch, and are ex- 
quisitely sensitive. Observers differ as to whether the nerve supply 
to the tumor is marked, some claiming to find a large nerve distri- 
bution, others to find none. As they are exceedingly tender, the 
inference may be drawn that they are well supplied with nerves. 

Symptomatology. — Unless the tumors be of large size the patient 
may go on for a long period without experiencing anything more 
than a slightly irritable condition of the urethra. When, however, 
the tumors become large, or are of the polypoid angioma variety, the 
pain is markedly increased, and the obstruction to the outflow of 
urine becomes very apparent. These tumors, by constant moisture 
and friction, become eroded on their surface, and these ulcerations, 
being constantly aggravated, give rise usually to slight hemorrhage 
and increased pain. Retention of urine may result from their clos- 
ing the urethra. 

Of all the urethral neoplasms, however, the papillary polypoid 
angiomata are the most intensely painful, and patients retain their 
water for a long time to avoid the agony that is produced by passing 
it. The pain is, in some cases, present at all times, and is greatly 
aggravated by sitting or lying down. The clothes coming in con- 



840 DISEASES OF WOMEN". 

tact with, the exquisitely sensitive surface often produce vaginal and 
anal spasm. Coition is sometimes impossible. A case is related of 
an old woman thus affected, who, though married some thirty years, 
was still a virgin. Indeed, this affection is sometimes mistaken for 
vaginismus, and treated accordingly. The directions which I shall 
give under the head of diagnosis will, I think, be sufficiently plain 
to prevent such mistakes. 

Even when these tumors are too small to obstruct the urethra, 
obstruction may occur from severe spasm due to the pain caused in 
the act of micturition. 

Bleeding from these tumors is not uncommon, but it seldom 
amounts to much, and is easily controlled. 

The pain in any of these new growths is not always confined to 
the urethra, but may be felt in the back, hips, suprapubic region, 
thighs, knees, and feet. In carcinoma lancinating pains may be 
present, but this is by no means the rule. 

As the tumors increase in size, the urethra becomes gradually 
dilated, and the mucous membrane eroded, hyperaemic, and catarrhal. 
Its structure may become loose, flabby, and vascular, and a pouch 
form behind the tumor. If far enough back to interfere with per- 
fect closure of the vesical neck, incontinence may occur, and incon- 
venience and distress the patient greatly. 

Sometimes the bleeding is severe, and the patient suffers from 
angemia caused thereby. This is more usually the case if, in the de- 
structive process attending carcinoma, an artery of any considerable 
size is opened into. This accident, however, rarely occurs. 

In the extremely painful neoplasms, the face gives evidence of 
constant pain, distress, and anxiety ; and in the most aggravated 
forms patients are pale, emaciated, and extremely low-spirited, often 
wishing earnestly for death to relieve their sufferings. 

If the tumor be of sufficient size to be a serious bar to free mic- 
turition, cystitis, pyelitis, and more serious results, as renal destruc- 
tion, are to be feared. 

The presence of small, and even large tumors, in the urethra 
and about the meatus often gives rise to increased sexual desire, that 
is gratified in the young girl by masturbation. 

The urine is normal, save that it contains the products of urethral 
disease, viz., epithelium, pus, mucus, and sometimes blood. Small 
pieces of the tumor, small cysts or polypi, the pedicles of which 
have died or been torn through, are sometimes found in the urine. 

In cancerous neoplasms, as the disease invades the tissues to the 
second and third degrees mentioned in connection with malignant 



ORGANIC DISEASES OF THE URETHRA. 841 

tubercle, the patients gradually sink and die from exhaustion from 
severe bleedings, loss of rest, and general cachexia. Some cases, 
however, do not succumb until long after the third degree has been 
reached, with extensive destruction of tissue. 

Diagnosis. — The diagnosis of urethral neoplasm is really quite 
easy, provided the investigation is thoroughly and intelligently con- 
ducted. When a woman comes to the physician complaining of 
pain on micturition, pain in sitting, obstructions to or interruptions 
in the flow of urine he should at once proceed to a thorough investi- 
gation of the parts, first by the eye and touch, and second by the 
aid of the speculum, endoscope, and an examination of the urine. 
If the tumor presents at the meatus, it will, of course, be readily 
seen, and can be easily diagnosticated. 

If in the urethra, the finger passed along the course of the ure- 
thra in the vagina, with some dilatation of the meatus, will discover 
it. If of small size, the endoscope, with a strong light, will give an 
excellent view of it. If the tumor be exquisitely sensitive, as 
some are, the patient should be wholly or partially anaesthetized, and 
then the examination can be fully and freely made. Vaginismus 
may be excluded by passing the finger into the vagina, away from 
the urethra, when no spasm will take place ; but if the urethra is 
touched, the spasm is at once produced. 

To determine whether the inflammatory mischief, when it exists, 
resides in the urethra alone, the patient should be directed to pass 
one half of her urine into one vessel, and the other into another. If 
the trouble is seated in the urethra only, the last urine passed will be 
totally or almost wholly free from the inflammatory products. The 
same may be accomplished also by drawing off the urine with a 
clean catheter. 

In some cases the varicose condition of the vessels of the nmcous 
membrane, with considerable swelling, may simulate prolapse of the 
mucous membrane. If, however, the blue discoloration is borne in 
mind together with the elastic feel, and the reduction in size under 
compression of the urethral haemorrhoids, there will seldom be any 
error in the diagnosis. Of course, prolapse of the mucous membrane 
and a varicose condition of the urethral veins sometimes coexist, and 
this must not be forgotten. 

Tumors, usually those of large size and pedunculated, often cause 
some degree of prolapse of the mucous membrane by constant drag- 
ging. A prolapsus of the mucous membrane may also simulate a 
tumor. The position of the meatal orifice, and the fact that it can 
be reduced, will distinguish the prolapse. 
55 



842 DISEASES OF WOMEN. 

To distinguisli one kind of tumor from another is not always 
easy, but with a Httle care it can be accompHshed. The condyloma 
will be recognized by its painlessness, its warty, cracked, pinkish 
white or white surface, and the fact that similar growths are at the 
same time usually found on the vestibule. The polypoid angioma 
will be known by its bright-red surface, its tendency to bleed 
easily, and the exquisite pain produced when touched. The sar- 
coma will be readily confounded with the angioma, but it is very 
rarely found here ; and if there is any doubt, a little piece may 
be scraped off with the cnrette, and examined microscopically. 
Should doubt still remain, the history and progress of the disease 
will soon determine the nature of the trouble. The malignant tumor 
will grow much faster than the other. The varices can be told by 
their bluish color and their shrinking under pressure, and the cysts 
and fibromata by their smooth, painless surface, normal mucous cov- 
ering, and their consistence. 

Carcinoma appears, as I have already said, as hard tubercles 
(usually periurethral), which after a time break down. When this 
occurs, the endoscope, the lancinating pains (if present), the rapid 
invasion of neighboring tissue, and the composition of the diseased 
mass, under the microscope, will tell the story. 

Prognosis. — The simple forms of urethral tumor are easily 
removed, and do not return. As a rule, therefore, the prognosis 
is good. Of this class are cysts, condylomata, mucous polypi, and 
fibromata. 

The angiomas are of a more serious nature, as by the pain and 
suffering which they cause the constitutional condition is usually low ; 
and, though they may be extirpated, they are likely to return and 
rapidly increase in size, even in from one to three months' time. 
Although the bleeding from these tumors is rarely very great, still 
there may be numerous small haemorrhages, and at times severe 
ones, either from the urethra externally or into the bladder. Under 
proper treatment, however, there is always a possibility, and in some 
cases, a certainty of cure. 

In carcinoma there is no hope of effecting a cure, although the 
patient's condition may be much improved in some cases. Death 
usually ensues before the third degree is reached. Almost the same 
may be said of epithelioma, unless it is treated in its early stages. 

Causation. — The causes of the various neoplasms are not yet 
clearly made out, and will not be, I think, until more extended ob- 
servations are made on the subject. Even then it is more than 
probable that some of them will remain obscure. 



OEGANIC DISEASES OF THE URETHRA. 843 

The predisposing causes are a laxitj of the urethral tissues, with 
a tendency to a varicose condition of the parts, usually found in old 
age ; a general tendency to venous stagnation, catarrh of the mucous 
membrane, and dislocation of the urethra, partial or complete. 

As a proof that no single special cause produces these condi- 
tions, it may be said that these growths have been found congeni- 
tally, and at every period during life, as late indeed as the ninety-sec- 
ond year. 

The exciting causes, as given by different authors, vary. The 
following are some of those usually mentioned : 

1. Temporary or clironic congestion of the urethra during preg- 
nancy, uterine and ovarian tumors, and obstructed portal circulation. 

2. Injuries to the parts during labor, external violence, the irri- 
tation of chronic and acute urethritis (specific or simple), syphilitic 
poison, and masturbation. 

Of coarse, the carcinomata, cysts, and simple mucous polypi, are 
not here included, although some of the above causes might aggra- 
vate if not produce them, for I have already spoken of their method 
of causation as far as it is known. Cancer occurs by extension of the 
disease from other parts ; cysts and mucous polypi, from occluded 
duct orifices. This narrows the list to the nervous class and the 
compound, viz., the polypoid angiomas. And of these I may vent- 
ure to say that any cause, such as constant irritation, sudden injury, 
or slow congestion, may produce these conditions, especially in 
those who are somewhat predisposed ; but that any one cause, such 
as the gonorrhoeal poison, is sufficient to produce them, in all cases, 
is more than doubtful. 

Most of these tumors occur in married women, both in those 
who have borne children and in those who have not. 

It might be supposed from all that has been said upon this sub- 
ject that urethral neoplasms are very common. On the contrary, 
they are very rare, with the exception of polypoid angiomas. 

Treatment.— ThQ treatment of these cases is, in most instances, 
entirely surgical, but when the general system is deranged in any 
way it should receive careful attention. If there is a congested 
condition of the urethra, the portal circulation should be kept in a 
normal state by securing a healthy action of the liver and bowels. 
The condition of the circulation in the part involved may possibly 
be influenced by constitutional medication. For this purpose, 
ergot, digitalis, and nux vomica, in small doses regularly repeated, 
may be of service. These remedies will at least aid in securing a 
good general circulation, and may influence favorably the local affec- 



844 



DISEASES OF WOMEN. 




242. — Skene's urethral speculum. 



tion. If there is local congestion due to pressure on the pelvic ves- 
sels, the cause, interfering with the return circulation, should be 
removed, or remedied, if possible. 

The local treatment recommended by the various authors differs 
widely, but has the same end in view, viz., destruction or removal 
of the abnormal growth. The various methods of extirpation em- 
ployed are ligation, torsion, excision by the knife, scissors, curette, 
ecraseur, galvano-cautery, caustics, and electrolysis. Any one of 
these methods may be made to answer in all cases, but a judicious 
selection, according to the location and nature of the neoplasm, is 
advisable. A combination of means is best at times, as, for in- 
stance, excision by the scissors and cauterization afterward. 

Whatever method may be chosen the patient should first be 
placed in the lithotomy or in Sims's position, on the left side, which 
I prefer, and the part to be removed exposed by a speculum. 

There are two instruments which I use for this purpose. The 

first is here shown. Fig. 
242. It is made on the 
principle of Sims's specu- 
lum, the ends being of dif- 
ferent sizes. An elevator 
is attached at the central portion between the blades, and so arranged 
that when it is closed on one blade it is thrown out from the other. 
This is seen in the figure. The elevator is pressed dovni on the 
blade, and the instrument introduced, and then by pressing on the 
other end of the elevator the urethra is distended to its full natural 
capacity. When it is necessary to expose one side of the urethra 
completely, the elevator should be removed, and the instrument used 
in the same way that Sims's speculum is em- 
ployed in the examination of the vagina. 

The other instrument is a modification of 
Folsom's nasal speculum, made of wire, Fig. 
243. By turning the nut-screw the blades are 
closed, and the instrument is introduced ; and 
by unscrewing it the elasticity of the handle 
throws the blades apart. This instrument an- 
swers well when the tumor to be removed is 
small, and we are obliged to operate without as- 
sistance. It is self-retaining. The other spec- 
ulum is preferable in most cases, but, in operat- 
ing through it, it is requisite that some one should hold it. 

When the tumor is at or near the meatus, and has a large base, 




Fig. 243.— Skene's modi- 
fication of Folsom's 
nasal speculum. 



ORGANIC DISEASES OF THE URETHRA. 



845 



or if it is vascular and troublesome haemorrhage is feared, removal 
by ligature is preferable. Having exposed the part with the specu- 
lum the base of the tumor is to be transfixed by passing a needle 
from without inward, parallel to the axis of the urethra ; a ligature 
is then to be passed around under the needle, then the tumor is 
grasped with a forceps, and traction made so as to bring the sides of 
the base within the grasp of the ligature, which should then be tied 
slowly and as tightly as possible without cutting the tissues. By 
taking all these precautions the ligature will be certain to include 
all the abnormal tissue, a very important result indeed. If the base 
of the growth is too large to be included easily in one ligature, 
transfixion may be made; with a needle armed with a double thread, 
and its two halves tied. 

In choosing the material for a ligature, I would advise the use 
of fine plaited silk, boiled in a mixture of beeswax, carbolic and 
salicylic acids. A ligature prepared in this way ties easily, does not 
stick like the ordinary ligature, and, more than that, it does not slip. 

If the tumor is within easy reach and is pedunculated, the pedi- 
cle can be seized with a small forceps, and the tumor grasped in a 
polypus-forceps, and removed by torsion. Or it can be cut oft with 
the knife or scissors, and, if the pedicle inclines to bleed, touched 
with caustic. Allen's polypus-forceps for the ear will be found one 
of the most conven- 
ient instruments for 
taking hold of these 
little tumors, Fig. 
244. 

In cases where 
there are several 
small growths high 
up in the urethra, 
they can be removed 
with the curette, and, 
when the haemor- 
rhage has subsided, 
the base of each 
should be cauterized. 

But little difficul- 
ty will be experienced in operating in the various ways described 
when the neoplasms are low down in the urethra, where they can be 
easily seen and handled. When they are high up in the canal, then 
great skill and care are required to remove them. In such cases 




Fig. 244. — Allen's polypus forceps. 




346 DISEASES OF WOMEN". 

success will be best obtained with the ecraseur, or the instrument 
known as Blake's polypus-snare, used for removing polypi from the 
ear, Fig. 245. It is simply a very delicate ecraseur, the chain or 

wire of which is 
C> g '^ fe^ tightened by the 

G.TIEMANN ikCO. Y^^^a r- • n ^ 

linger m place oi 
a screw. It will 
be found that, in- 
stead of the wire 
^, , , , commonly used, 

Fig. 245. — Blake's polypus snare. i • 

the steel - wire 
string of the zither is better ; it is stronger, more elastic and pliable, 
yet stiff enough to be manageable. Dr. John W. S. Gouley, of New 
York, was the first to use this instrument for removing tumors of 
the urethra, and I can testify to its great value in such operations. 

In operating with the snare, the tumor is exposed with the 
urethral speculum ; and, if the growth is pedunculated, the loop of 
wire is passed over it, and removal effected by constriction. When 
there is a broad base, the whole mass is seized with the polypus-for- 
ceps, and the snare is then passed over it and tightened until it 
comes away. 

There is one accident that very often occurs in this operation, 
and that is breaking of the wire. This takes place, usually, just 
when the tumor is almost cut off, and it annoys and hinders the 
operator, but does not spoil the operation, as a new piece of wdre 
can be used, and the operation completed. This accident can often 
be avoided by taking time. The base or pedicle of most of these 
growths will give way under long-continued pressure, but the wire 
will break if there is too much hurry. 

In order to operate high up in the urethra, it is sometimes 
necessary to dilate its lower portion. A convenient way to do this 
is the following : Take a piece of fine rubber tubing and draw it 
over the blades of the Folsom speculum, and then introduce the in- 
strument into the urethra. Open the blades, and let it distend the 
Urethra as far as it can. To produce the extra dilatation, take a 
series of graduated sounds or dilators — wood or hard rubber will 
answer — and force one of these in between the blades of the specu- 
lum ; remove that one, and use a size larger, and so on until the 
requisite amount of dilatation is obtained. The blades of the specu- 
lum and the rubber tubing protect the mucous membrane of the 
urethra from injury while passing in the dilator. The danger of in- 
continence of urine, which is liable to follow from forcible dilata- 



ORGANIC DISEASES OF THE URETHRA. 847 

tion, can be avoided by distending the lower portion of the urethra 
only. 

To obtain sufficient light for operating high up in the urethra, 
it is necessary to have clear sunlight ; or, if that is not obtainable, 
gaslight should be used ; and, in either case, the concave head-mir- 
ror should be employed. 

Of late years the galvano-cautery has been very extensively 
used in surgery generally, and has been recommended for the re- 
moval of urethral tumors. As a means of removing large and vas- 
cular growths from the meatus, it has high claims, but for general 
use it will be found objectionable. In removing tumors from the in- 
terior of the urethra with this cautery, it is impossible to avoid cau- 
terizing portions of the normal membrane unless extraordinary skill 
is employed. This unfortunate liability, and the difficulty in keep- 
ing the instrument in good working order, stand in the way of this 
means of operating ever becoming popular in this department of 
surgery. 

Caustics have been more extensively used than any other means 
of removing urethral neoplasms, and I know of no better way of 
destroying small growths. Of all the agents used, I prefer pure 
nitric acid, which I use as follows : Exposing the tumor with the 
speculum, represented by Fig. 245, I wrap a little cotton around a 
probe, and dip it into the acid, and apply it to the part to be de- 
stroyed, taking care not to touch any of the normal tissues. The 
speculum recommended has the advantage of protecting one side of 
the canal, and, by exercising care in handling the acid, accidents 
may be avoided. 

I come now to the last method of removing these tumors which 
I shall mention, viz., electrolysis. This means of treating abnormal 
growths has been employed so much lately that I need not dwell 
upon the method of its use, but simply state that those tumors that 
recur, and those that are suspected to be malignant, and those also 
that are so high up in the urethra as to be difficult to remove, should 
be treated by electrolysis. Two long, slender needles should be in- 
sulated by coating them with collodion, except at the points. These 
are attached to the electrodes of a galvanic battery, and their points 
introduced into the base of the tumor, and the current passed through 
until the whole of the abnormal tissue is decomposed. I pi-efer to 
use a current sufficiently strong to char the tumor, and thereby com- 
pletely destroy it. 

There is one rule which should be kept in mind in treating 
tumors of the urethra, and that is, to be sure to remove all the al> 



84:8 DISEASES OF WOMEN. 

normal tissue. Whatever raethod is employed, no portion of that 
which ought to be removed should be left. I am confident that 
much of the trouble expericDced by the repeated return of these 
growths might be avoided by a careful observance of this rule. 

Urethral catarrh or inliammation, which frequently accompanies 
abnormal growths, usually subsides after their removal. In some 
cases it persists, and then it should be treated according to the 
methods already given. 



CHAPTER XLYII. 

OKaANIC DISEASES OF THE URETHRA (cONTINUEd). 

DILATATION, DISLOCATION, AND PROLAPSUS. 

5. Dilatation of the Urethra. — Changes in the caliber of the female 
arethra occur in two forms, dilatation and contraction ; but neither 
of these is very often met with in practice. Of the two, dilatation 
is the more common. The increase in the size of the nrethra may 
involve the whole canal, or be limited to a portion of it. I will first 
speak of dilatation of the whole urethra, and then, dividing the canal 
into thirds, consider the affection of each portion. 

Dilatation of the Whole Urethra. — It will be understood that dila- 
tation to such an extent as to have the canal open and its walls sepa- 
rated is an unknown condition. The true state of things would be 
more correctly expressed by calling it an abnormal dilatability. The 
tissues of the walls of the urethra are in such a relaxed condition as 
to admit of extraordinary distention without injury. Dilatation of 
the whole urethra is not so common as dilatation of a portion. Even 
when the whole canal is larger than it should be, it will generally be 
fonnd that it is not uniformly so. Some portions of it are more 
distended than others. The extent to which this dilatation may 
occur is very great. A number of cases are recorded, especially in 
the German literature of the subject, where copulation took place 
for years in the urethra instead of the vagina. In these cases the 
dilatation was extreme. 

In this affection the urethral walls and the ure thro-vaginal sep- 
tum are usually relaxed and flabby. After a considerable time they 
may become indurated by infiltration, or by hyperplasia of the con- 
nective tissue. The mucous membrane is usually soft and loosely 
adherent to the subjacent tissues. Beneath the membrane will some- 
times be found masses of enlarged veins, which give a dark-bluish 
appearance to the parts. If the meatus be distended like the rest of 



850 DISEASES OF WO^EX. 

the urethra, the mucous membrane, with the lai'ge veins beneath it, 
may protmde and form tumors, which will have quite the appeai'- 
ance of rectal haemorrhoids. This is especially so when the veins 
are large and numerous, and the mucous membrane thin, so that 
the color of the veins can be seen thi'ough it. On the other hand, 
if the meatus remains normal in size nothing will be seen by the 
examiner until the catheter or sound is passed into the m-ethra, 
when the distended or distensible condition of the canal will be de- 
tected. The dilatation can easily be made out, even when the meatus 
is normal in size, by observing that the sound can be moved about 
in the urethi'a, convening the same impression to the hand as when 
it passes into the bladder. By making a digital examination of 
the vagina the enlarged lu-ethra can be felt, and is usually elastic 
and compressible. Through Sims's speculum the abnormal fullness 
or bulging of the anterior vaginal wall can be plainly seen and dis- 
tinguished from displacement of the urethra. The points of differ- 
ence between dilatation and displacement will be brought out more 
in detail further on. 

When the dilatation has existed for any length of time, the 
mucous membrane is usually hvper?emic and sometimes catarrhal, 
secreting a muco-purulent material, which may be seen escaping from 
the meatus, or lodged in the folds of the membrane, where it can be 
observed through the endoscope. "When the mucous membrane is 
prolapsed and forms a tumor outside of the meatus, it soon becomes 
lissured and ulcerated, and consequently very tender and painful. 
This condition is produced by the retarded circulation, chafing, and 
the irritation from exposure to the air, and the urine passing over it. 

Dilatation of the Anterior or Lower Third. — This is the rarest of 
all the forms of ui'ethi-al dilatation, and occurs usually as a conse- 
quence of some enlargement or swelling of the mucous membrane, 
neoplasm of the urethra, or mechanical dilatation. The dilatation 
may include the meatus or it may not. In rare cases it does not at 
first, but later in the course of the trouble the enlarged mucous 
membrane slowly, sometimes rapidly, dilates the orifice. The gen- 
eral appearances of the parts are the same as those of which I have 
spoken under the head of dilatation of the whole urethra. When 
the dilatation is due to any abnormal growth in the urethra, the 
conditions presented will be the same as those already described 
undei the head of urethral neoplasms. 

I have seen but one case where the lower end of the urethra 
was dilated without any recognizable cause for it. This was a sin- 
gle lady, thirty-five years of age, a school-teacher. She had dis- 



ORGANIC DISEASES OF THE URETHRA. 851 

placement of the uterus and catarrh of the cervical canal, for which 
she consulted me. She had no trouble with her urinary organs. 
While examining the uterus I noticed that the meatus urinarius was 
peculiarly formed. In place of the concentric corrugations of the 
mucous membrane which form the closed meatus, the orifice was 
funnel-shaped, and lay open when the labia minora were separated. 
About half an inch of the lower end of the urethra admitted a 
No. 21 (English) sound. The remainder of the urethra was normal, 
and there were no signs of disease about the mucous membrane of 
the dilated portion. I could obtain no history which pointed to the 
origin of the dilatation, and it caused no discomfort to the patient. 

Dilatation of the Posterior or Upper Third. — This form of dilata- 
tion usually occurs in connection with other pathological conditions, 
such as prolapsus of the bladder and urethra. On this account I 
will defer what is to be said on this subject until I come to disloca- 
tions of the urethra. 

Dilatation of the Middle Third of the Urethra. — Dilatation of this 
part of the urethra is more common than either of those I have 
described. I do not desire to be understood as saying, that it is con- 
fined to exactly the middle third of the urethra, or that the other 
dilatations are confined to thirds only. It is about a third, and I 
use the division to fix the idea clearly in the mind and for conven- 
ience of description. 

In this form of dilatation the anterior wall of the urethra main- 
tains its normal position, but the central portion of the canal being 
distended settles down, so that in time the urethra, in place of be- 
ing a straight or slightly curved canal, becomes triangular, the 
upper wall being the base, and the central portion of the posterior 
wall (that is midway between the neck of the bladder and the 
meatus) the apex. A cavity is thus formed in the central portion 
of the urethra. Fig. 246 will convey the idea of the anatomical 
appearances of this affection. 

This form of dilatation has been called sacculated urethra and 
urethrocele. A valuable article on this subject will be found in the 
" American Journal of Obstetrics " for February, 1871, by Nathan 
Bozeman, M. D. Some of the cases related there by him are, in 
my opinion, not simply urethral dilatation alone, but dilatation and 
dislocation combined. However, his description of this form of 
trouble is the best that I have ever seen, and I prefer to give it in 
his own words. It is as follows : 

" In the study of urethrocele, the anatomical points to be consid- 
ered are the triangular ligament and its relations with the urethra, 



852 



DISEASES OF WOMEN. 



the muscular structure of the urethra, and the different relations of 
the urethra to the vaguia in the upper and lower parts of its course. 




Fig. 246. — Dilatation of middle third of the urethra (urethrocele). 

" These anatomical peculiarities exert a marked influence on the 
etiology of the lesions in question, and supply the first links in the 
long chain of morbid results indicated by the histories of the cases 
above cited, and others known sometimes to follow. 

" In the male, stricture, although not the first morbid alteration, 
denotes the first serious interruption of the stream of urine, and 
superinduces morbid changes in the urethra above the prostate 
gland, in the bladder, the ureters, and the kidneys. 

" In the female, rare as it is to meet with organic stricture of the 
same kind as in the male, the caliber of the canal is quite as often, 
if not oftener, compromised, and with due allowance for the ana- 
tomical differences of sex, the pathologic sequences observe the 
same order. 

"^ The starting-point of urethral and vesical lesions in the female 
is to be sought in the lower half of the urethra, closely related in 
front with the triangular ligament, and blending behind with the 
spongy erectile tissue of the vagina. 

" The caliber of the urethra may be transiently narrowed by 



ORGANIC DISEASES OF THE URETHRA. 853 

congestion of its mucous lining, or permanently narrowed by infil- 
tration of coagnlable lymph into the underlying cellulo-elastic tis- 
sue, which constitutes properly the so-called organic stricture, as in 
the male, and which, however seldom met with, is liable to the same 
sequences. 

'' Infiltration into the spongy erectile tissue outside the urethra, 
by plastic lymph, is, I believe, by far the most common beginning 
of the morbid process, whatever be the cause that produces it. This 
interrupts the stream of urine, either by encroaching on tbe caliber 
of the urethra, or by deflecting it beneath the triangular ligament, 
both cases being attended with more or less dilatation above. 

" The next step in sequence is increased functional activity of the 
urethral muscular coat in overcoming the obstruction to the flow of 
urine. The result upon its structure is hypertrophy, and this will 
be of the eccentric type, thickening the urethral walls while enlarg- 
ing the caliber. Hence the ease with which large catheters of a 
proper curve pass at all stages of the disease. False and true hyper- 
trophy here coexist. The true hypertrophy increases jpari jpassu 
with the muscular contraction, and is followed by still greater distor- 
tion of the canal, at an angle more and more acute, as it turns the 
triangular ligament, and with corresponding coarctation of its walls 
at that point. This mechanical impediment below coincides with 
the increased weight and volume of the stream of urine above, to 
put the walls of the urethra on the stretch in the upper part of its 
course. 

" Thus is gradually formed the urinous tumor, whicb drags down 
in front the adjacent vaginal wall, appearing as a prolapsus between 
the nymphge, and fllling up the ostium vaginae. 

" The looser attachment of the urethra to the vagina in the upper 
part of its course facilitates this result. Such is the condition of the 
parts to which I apply the term urethrocele. Often confounded 
with cystocele, it is really distinct. 

" The arrest and retention of but a few drops of urine at first 
goes on until this may amount to a teaspoonful or more. It is then 
decomposed in this pocket, becomes alkaline, and by its irritation 
provokes congestion of the urethral mucous membrane.'' 

In the earlier stages of this affection the urethra in front and 
behind the pouch is really or apparently contracted ; but as the 
disease progresses the upper part of the canal and the neck of the 
bladder become dislocated downward, and finally the upper portion 
of the urethra becomes also dilated to some extent. 

There is in this, as in the other forms of urethral dilatation, fre- 



854 DISEASES OF WOMEN". 

qiient "urination, usually more marked ; but unlike the others, there 
is difficulty in passing water. This frequency of urination, and 
the straining efforts necessary, affect the bladder, producing irri- 
tation, and, in time, liypertropby of its walls. Cystitis also follows 
in the order of morbid developments ; but whether that comes 
from the frequent and difficult urination, or from extension of the 
inflammation from the urethra to the bladder, is a question. One 
thing we know, and that is, that if this form of uretlu-al dilatation 
goes on without treatment, cystitis will sooner or later appear. 

Symptomatology. — The symptoms vary according to the extent of 
the dilatation, the portion of the urethra involved, and the condition 
of the mucous membrane. When the whole urethra is dilated, the 
only symptom present may be frequent urination. When there is 
inflammation or prolapsus of the mucous membrane, then pain will 
be caused by micturition, and the desire to micturate will be more 
urgent and frequent. The patient may also be annoyed by a slight 
loss of control of the bladder, under the pressure of lifting heavy 
weights or coughing. 

Dilatatation of the lower third of the urethra does not cause any 
derangement of function, unless accompanied with inflammation or 
ulceration ; then there will be frequent urination possibly, painful 
urination certainly. The symptoms in this form of dilatation are 
less marked than in the other varieties. 

When the trouble is located in the upper third of the urethra, 
the symptoms are sometimes very distressing. In addition to the 
frequent — it may be constant — desire to pass water, the patient is 
tormented with partial incontinence. Coughing, laughing, sneezing, 
stooping to lift anything, a jar on stepping from the curbstone in 
crossing the street, causes an escape of urine. This distresses the 
patient very greatly. She is not troubled so long as she keeps quiet, 
or at least she suffers only from frequent urination ; but as soon as 
she undertakes the usual duties of exercise or enjoyment, then this 
partial incontinence makes her miserable. From the constant wetting 
of the external parts they become inflamed, unless very great care is 
taken to keep them dry and clean. In some of these cases the morti- 
fication is sometimes more distressing than the physical suffering. 

The symptoms occurring in dilatation of the middle portion of 
the urethra (urethrocele) are the same as those already given, with 
the addition of a slight mechanical obstruction, which causes difficult 
urination. That is, more voluntary effort is necessary on the part of 
the patient to empty the bladder. The forcing, straining efforts 
made by some of these patients while urinating are even greater 



OEGANIC DISEASES OF THE UKETHEA. 855 

than the mechanical obstruction appears to account for. This may 
be due to the accumulation of urine in the urethra, which excites 
extra reilex action in the bladder and urethra out of proportion to 
the obstruction. This is the only way that I can account for the 
difficult urination and muscular hypertrophy found in these cases in 
which there is no obstruction from stricture. 

The constitutional symptoms arising from these urethral troubles 
are the same as those produced by urethritis, and are not peculiar to 
this class of affections. In fact it will be observed that the symptoms 
here given may all be produced by other pathological conditions, and 
consequently can not alone guide to correct diagnoses. The clinical 
history in such cases leads us to suspect the nature of the disease, 
but the true character of the trouble can only be discovered by 
physical exploration. 

Diagnosis. — In dilatation of the whole urethra, a digital exam- 
ination will detect the increased space occupied by the urethra. The 
canal encroaches upon the anterior vaginal wall, and feels like a 
ridge extending from the meatus to the neck of the bladder. This 
elevation or thickening of the urethra is elastic and compressible in 
recent cases ; in those of long standing where there is hypertrophy, 
the tissues are firm to the touch, but still the canal is compressible. 
The extent of the dilatation can be measured by the size of the 
sound that can be easily passed. If even the ordinary female catheter 
is at hand an idea of the size of the canal may be obtained. By 
introducing that instrument and pressing it first against the anterior 
wall and then upon the posterior, the distance between the two can 
be approximately made out. While the catheter or sound is in the 
urethra the finger should be introduced into the vagina and the 
thickness of the urethral wall ascertained. This will give a good 
idea of the increase of tissue from inflammatory products or hyper- 
trophy. 

When the meatus is dilated and the mucous membrane and en- 
larged vessels are prolapsed, care must be exercised to distinguish 
that condition from urethral neoplasm. This can be done by ob- 
serving that in prolapsus the opening is situated either at the upper 
side or in the center of the protruding mass, whereas in abnormal 
growths of the urethra the meatus surrounds the tumor or its 
pedicle. More than that, by making pressure on the distended 
vessels the size of the prolapsed membrane can be reduced, and the 
membrane can be pushed up into the canal. This can not usually 
be done with tumors. 

Dilatation of the lower third of the urethra is easily diagnosti- 



856 DISEASES OF WOMEN. 

cated. A large sound will pass in as far as the dilatation extends, 
and will be arrested when it comes to that portion of the canal which 
has a normal caliber. 

Great diflScultj will be encountered in the diagnosis of dilatation 
of the upper third of the urethra, but by attention to the following 
points success will usually follow. By using the sound it will be 
observed that while the lower portion of the canal hugs the instru- 
naent firmly, the point of it can be moved freely in the upper part 
of the passage. The same impression is conveyed through the in- 
strument as that which is experienced when the sound enters the 
bladder ; only in dilatation of the upper portion of the urethra, the 
motion of the point of the so and is, of course, more limited. Again, 
by introducing a curved sound, and with it holding the anterior wall 
of the urethra well up under the arch of the pubes, and then carrying 
the finger of the other hand along the anterior vaginal wall, the 
posterior wall of the urethra will be found to hug the sound until 
the dilated portion is reached ; this will be felt to lie away from the 
instrument. By pushing up the vaginal and urethral walls at the 
point of dilatation until they touch the sound, and then by remov- 
ing the pressure and allowing the parts to recede from the sound, 
the relaxation can be easily detected. 

In some well-marked cases of dilatation complicated with pro- 
lapsus of the upper portion of the urethra, the diagnosis can be 
clearly made, by slowly introducing the catheter until the urine be- 
gins to flow, and then marking the catheter at the meatus urinarius 
and withdrawing it. The distance from the mark made to the 
upper edge of the eye of the catheter indicates the length of the 
normal portion of the urethra. If that is subtracted from the 
normal length of the urethra, the remainder will indicate the length 
of the dilated portion. 

Dilatation of the middle third of the urethra — urethrocele — is 
most likely to be confounded with thickening of the urethro-vaginal 
septum. The diagnosis is made by observing that the enlargement 
due to dilatation corresponds to the central portion of the urethra, 
and that it yields to pressure more or less. Also, by passing a 
curved sound with the point upward, the anterior wall of the urethra 
will be found to occupy its normal position. Withdrawing the sound 
and again introducing it with the point downward it will pass in- 
ward and then down into the pocket found at the point of dilatation, 
where it can be felt through the vaginal wall. 

In all cases, except one, that have come under my observation, 
the diagnosis has been easily made by this method of examination. 



ORGANIC DISEASES OF THE URETHRA. 857 

The exception referred to was a case of periurethral inflammation, 
in which an abscess formed in the urethro-vaginal septum and dis- 
charged into the urethra. A fistulous opening from the floor of the 
urethra into the sac of the abscess remained. The urethra occupied 
its normal position, and admitted the sound easily; and bj intro- 
ducing it with the point downward it passed into the sac of the 
abscess, thus giving the physical signs of urethrocele ; but the small 
size of the opening in the floor of the urethra, the marked infiltra- 
tion and induration of the tissues, and the history of the case, led 
to a diagnosis of its true character. 

Prognosis. — There is no natural tendency to recovery in these 
affections. If left alone they generally get worse ; recovery under 
treatment is modified by the location of the dilatation and the dura- 
tion of the trouble. The conditions upon which an unfavorable 
prognosis is to be based are bladder complications, inflammation or 
ulceration near the neck of the bladder, great varicosity of the veins, 
and fatty degeneration of the muscular tissue. In the absence of 
all these complications a complete cure can be obtained. In all 
cases great relief can be secured by treatment, and the patient 
guarded from getting worse. 

Causation. — The hypersemia of the urethra whicb occurs in 
pregnancy, and which tends to produce overdistention of the veins, 
favors dilatation of the whole urethra. It is not uncommon to find 
an apparent increase of tissue in the walls of the urethra during 
utero-gestation, and the dilatability of the canal is often increased 
also. This condition of the parts disappears during the involution 
which takes place after delivery ; but when from any cause the 
process of involution is interrupted, the enlarged vessels and relaxed 
condition of the urethral walls remain and sometimes increase. 
When to this state of the parts a catarrh of the mucous membrane 
is added, the enlargement of the membrane by swelling still further 
increases the caliber of the canal. 

The dilatation caused by passing calculi may remain permanently, 
and the same may be said of the use of large sounds. Neoplasms 
obstructing the meatus, or stricture at that point, may so obstruct 
the escape of the urine as to cause dilatation at all points above. This 
is no doubt one of the most important and frequent causes of dilata- 
tion. Indeed, the recognition of this fact has led to the suggestion 
of treating stricture of the upper portions of the urethra by com- 
pressing the meatus, and then forcing the urine into the urethra and 
retaining it there. 

I have already stated that dilatation of the lower third of the ure- 
56 



858 DISEASES OF WOMEN. 

tlira is rare, and is usually due to inflammation of the mucous mem- 
brane at that point or to abnormal growths, the distention remaining 
after the causes that produced it have been removed. This and 
mechanical dilatation from any cause cover the etiology of this form 
of the dilatation. Baker Brown says that the meatus is always 
dilated when there is stone in the bladder. 

Regarding dilatation of the upper third of the m-ethra, I am in- 
clined to believe that it occurs in consequence of a partial prolapsus 
of the bladder and the upper end of the urethra. The displacement 
of these parts implies a relaxation of the tissues, caused originally, 
it may be, by injuries during confinement, and the prolapsus permits 
an unusual pressure of the urine upon the upper end of the urethi-a, 
and dilatation is the result. On the other hand, the prolapsus and 
the accom]3anying relaxation of the urethral walls may be sufficient 
to cause the dilatation, and the whole trouble can invariably be traced 
to child-bearing or anteversion of the uterus. The fact that the 
upper part of the urethra is torn from its attachment to the subpubic 
ligament, and thereby deprived of its normal supports, would incline 
it to dilate, and I presume that this is oftentimes the cause of the 
dilatation. 

One cause of dilatation of the middle third of the urethra (ure- 
throcele) has been sufficiently dwelt upon in Bozeman's description 
of the pathology of that aJffection — that is, narrowing of the lower 
end of the urethra. This does not explain the etiology of all cases, 
however, for I have seen this form of dilatation where there was no 
stricture or hypertrophy of the lower end of the urethra. In such 
cases I have traced the cause to childbirth, during which the pos- 
terior wall of the urethra had been pushed downward and contused, 
while the upper remained in its normal position. The relaxation 
caused by this overstretching of the urethral wall formed a small 
pocket in the central portion, which gradually dilated more and more 
by the pressure of the urine until the urethrocele was fully devel- 
oped. This explanation of the cause may be rather hypothetical, 
but, so far as my observations go, it agrees with the facts found in 
those cases which can not be accounted for by Bozeman's views on 
the pathology of this affection. 

Treatment. — In the management of all forms of urethral dila- 
tation, any inflammation of the mucous membrane that may exist 
should be relieved by employing the usual methods of treatment of 
urethritis. When there is a relaxed and prolapsed condition of the 
mucous membrane, astringents should be used to overcome it. Tan- 
nic acid will answer well. When these fail, the redundant mem- 



ORGANIC DISEASES OF THE URETHRA. 859 

brane should be retrenched, either by touching it with the thermo- 
cautery or excising a portion with the scissors. In employing the 
cautery for this purpose, the long-pointed tip of the instrument 
w^hich is used for cauterizing haemorrhoids by puncture should be 
chosen, and, having protected one side of the urethra with the specu- 
lum, a narrow strip of the membrane parallel to the axis of the 
canal shall be cauterized. Two or more of these cauterizations may 
be made at points equidistant on the circumference of the urethra. 
Operating in this way leaves pieces of normal membrane between 
the portions cauterized, which prevents stricture from occurring 
after healing — a misfortune which is sure to follow if the mucous 
membrane is destroyed by cauterization all round. 

In excising the prolapsed portion, I prefer to remove one or more 
Y-shaped portions on opposite sides, and bring the edges together 
by sutures. This is preferable to clipping off the whole of the pro- 
truding mass, because the cicatrices left are less likely to give after- 
trouble by contraction. 

When the dilatation is caused by varicose veins, it may be well 
to follow the example of Grustave Simon. He exposed the vessels 
by cutting through the vaginal wall, ligated the largest, and arrested 
the haemorrhage from the smaller ones by applying liquor ferri per- 
chloridi. He repeated this operation several times on the same pa- 
tient, who experienced little or no inconvenience from the proceed- 
ings, and made a good recovery. 

Dilatation of the lower third of the urethra is usually secondary 
to some other trouble, as I have already stated, and all that the physi- 
cian wiU usually be called upon to do for such cases is to remove the 
cause and treat any inflammation that may exist. The dilatation will 
then disappear, and, if it does not, but little, if any, trouble will result. 

The treatment of dilatation of the upper third consists simply in 
supporting the parts. This can be effectually done by using the 
pessary already recommended for the relief of prolapsus of the blad- 
der. It will be necessary to have the instrument so formed as to 
bring the pressure where it is required. This can easily be done by 
placing the pessary in position, and observing what change of form, 
if any, is necessary, and then directing the instrument-maker to make 
the alteration. If the parts are well supported in this way, recovery 
will follow, unless atrophy of the muscular wall has previously taken 
place. Even then the patient can be kept comfortable by wearing 
the pessary. If there is urethritis present, it may be necessary to 
relieve that before using the pessary ; otherwise, the pressure of the 
instrument may cause pain, and aggravate the inilammation. 



860 



DISEASES OF WOMEN". 



This brings me to the only remainiug form of this affection to be 
mentioned — dilatation of the middle third, or urethrocele. Dr. Boze- 
man has proposed making an opening into the most dependent part 
of the urethra through the vaginal wall, and maintaining it imtil all 
inflammation has been relieved, and then closing the opening bv the 
usual plastic operation. By this means the urethra is perfectly 
drained of urine and the products of inflammation which accumu- 
lated there before. This, with appropriate cleansing and topical 
applications, soon restores the mucous membrane to its normal con- 
dition, and the removal of the redundant tissue during the operation 
of closing the opening effectually cures the whole trouble. This 
treatment is admirably adapted to marked cases of long standing, 
and should be employed. By using the thermo-cautery to make the 
opening, the operation is easily performed. In recent cases of less 
severity, I have obtained satisfactory results by dilating the lower 
part of the urethra, and supporting the dilated portion either with a 
pessary or a tampon of marine lint. This permits the ui'ethra to 
keep itself empty, and then, by frequently washing it out and apply- 
ing such remedies as will cure the urethritis, recovery will sometimes 
follow. This treatment can be tried, and, if it fails, Bozeman's 
method can be resorted to. Dr. T. A. Emmet has extended the 
usefulness of this operation. He calls it button-holing the urethra, 
and employs the operation for diagnostic purposes as well as for the 
cure of various affections of the urethra and bladder. I have tried 
this operation as faithfully as I could, and find that it is easily per- 
formed by using a scissors modified, but like the button-hole scissors 
used by tailors (Fig. 247). 




24:1. — Button-hole scissors (Skene). 



The probe-pointed blade is introduced into the m-ethra, and the 
short blade into the vagina as far as the point at which the opening 
is to be made. One clip usually is suflicient, but if a larger opening 
be desired, it can be made by carrying the scissors up or down, and 
dividing as much more of the septum as may be desired. 

This operation is most thoroughly efficient for the purpose desig- 
nated for it by Dr. Bozeman, and it is also a convenient way of re- 
moving neoplasms situated in the middle and upper thii'ds of the 



OEGANIO DISEASES OF THE URETHRA. 



861 



urethra, when they can not be easily reached through the meatus 
urinarius. In regard to this operation, as a means of diagnosis, I 
have not been able to discover that it has any advantages, either to 
the patient or surgeon, over the methods I have already described. 
On the contrary, so far as simplicity, safety, facility, and efficiency 
are concerned, it is very inferior. 

6. Dislocations of the Urethra. — This is one of the affections that 
will frequently be met with in practice, although very little is said 
about it in text-books. I have found very few cases recorded in 
medical literature. This neglect of the subject by authors is perhaps 
due to the fact that in many cases of displacement of the urethra, 
the bladder is also dislocated, and the whole trouble is described 
under the head of vesicocele or cystocele. Now it is true that dis- 
placement of the two occurs together, but it will also be found that 
either may take place alone. It is not by any means uncommon to 
find prolapsus of the bladder while the urethra is in its normal posi- 
tion, and occasionally a case will occur in which the urethra is pro- 
lapsed, while thebl adder remains in its proper place. 

The urethra is subject to displacement upward and downward. 
In pelvic tumors the bladder is sometimes pushed up out of the pel- 
vic cavity, and the urethra dragged along with it. Usually no harm 
comes from this displacement, except that it may cause some difficulty 
in using the catheter, should this be necessary ; hence I need not 
dwell on this part of the 
subject. Dislocations 
downward are the most 
important because they 
occur more frequently, 
and almost invariably 
cause suffering to those 
so affected. 

The extent of dis- 
placement varies ex- 
ceedingly, but I shall 
describe only the par- 
tial and the complete. 
A clear comprehension 
of these two degrees 
will cover all interme- 
diate forms. In partial 
displacement downward, the upper two thirds of the urethra are pro- 
lapsed, so that the direction of that portion of the canal is backward. 




Fig. 248. 



-Dislocation of the upper third of the urethra. 
s, symphysis pubis ; k, rectum. 



862 



DISEASES OF WOMEN. 



instead of curving upward, as in the normal conditioUo Fig. 248 
will convey the idea of this degree of dislocation. 

In complete prolapsus the urethra runs from the meatus (which 
is in its normal position) backward, and rests upon the perinaeum ; or 
in extreme cases, accompanied with prolapsus of the bladder and 
uterus, its direction is backward and downward ; the position of the 
vesical end of the urethra being below the level of the meatus. In 
this degree of displacement the urethra and bladder can be seen pre- 
senting at the vulva, or lying between the labia minora or thighs. 



prolapsed 




Fig. 249. — Complete dislocation of the urethra with dilatation, u, urethra. 

The urethra is usually shortened considerably when the prolapsus is 
marked. Fig. 249 illustrates complete dislocation. 

Symptomatology. — The symptoms arising from displacement of 
the urethra are much the same as those found in dilatation and 
other urethral diseases. I need not, therefore, repeat them in detail. 
Suffice it to say, that in dislocation of the upper portion of the canal, 
there is, in addition to frequent urination, a partial loss of control of 
the bladder. Under the extra pressure of coughing, for example, 
the urine will escape. This loss of control does not exist, as a rule, 
in comjDlete displacement. On the contrary, there is usually diffi- 
cult urination, which requires increased voluntary efforts to empty 
the bladder. In some cases the bladder can not be emptied until 



ORGANIC DISEASES OF THE URETHRA. 863 

it is pushed up into position. In all degrees of displacement, the 
symptoms are increased in the erect position, and are markedly re- 
lieved when the patient lies down. 

Diagnosis. — An examination of the vagina, either by the touch 
or speculum, will reveal the downward projection of part or all of 
the urethra, which will demonstrate that there is either dilatation or 
prolapsus. The two conditions can then be differentiated by the use 
of the sound. The change in the direction of the canal will be 
shown as the sound passes in, and dilatation can be excluded by ob- 
serving that the urethra grasps the instrument firmly at all points. 
In dislocation of the upper two thirds of the urethra, it will be found 
that the sound passes in the normal direction, but is arrested at half 
or three quarters of an inch from the meatus ; but, by pushing up 
the vaginal wall and the urethra, the sound will then pass into the 
bladder. When the prolapsus is complete, the instrument passes in 
easily, but takes a downward and backward direction. 

Prognosis. — Uncomplicated displacement of the urethra can be 
remedied in the great majority of cases, if the trouble has not been 
of long standing, ^j placing the parts in proper position, and hold- 
ing them there, the relaxed tissues will usually contract sufiiciently 
to support themselves. Should they fail to do so, the patient can be 
at least made comfortable by wearing some supporter. In many 
cases the pelvic floor is imperfect, and by restoring it and bringing 
the parts together high up the urethra will be kept in place by the 
natural supports. 

Causation. — Utero-gestation and delivery are the most important 
causes of this affection. In the advanced months of pregnancy I 
have observed that, while the bladder rose above the pubes, the 
urethra was pushed slightly downward by the settling of the en- 
larged uterus into the pelvis. In such cases, when labor occurs, the 
head of the child dislocates the urethra still more, by pushing it 
still farther down. This process I have often watched in forceps 
delivery. When the child's head is large, and there is a partial pro- 
lapsus of the urethra existing before the forceps are applied, one can 
see during traction that the urethra and anterior vaginal wall are 
forced down before the advancing head, and that, too, while counter- 
pressure to prevent it is being made. The displacement produced 
in this way is often corrected during convalescence, if proper care be 
taken to push the parts back into place, and the patient kept at rest 
until the tissues regain their tonicity. But in many cases the trouble 
is overlooked, and, by permitting the patient to get up and be on 
her feet while there is still prolapsus, it will slowly increase, until 



864: DISEASES OF WOMEN. 

the dislocation is complete. This will surely be the case if there is 
any loss of perinseum. Indeed, rupture of the perinaeum is an acci- 
dent which permits the m-ethra to descend from its place. I believe 
that the perinseum supports the vaginal walls, which in tuna support 
the urethra ; and if the perinseum is lost, even in part, the vaginal 
walls become relaxed, or perhaps never regain their tonicity after 
dehvery, and, settling down more and more, carry the urethra wdth 
them. I need hardly repeat what has already been said, that dis- 
placements of the uterus often cause malposition of the bladder and 
urethra. 

Treatment. — When the displacement of the urethra is caused by 
any other affection, such as defective perinseum or prolapsus uteri, 
then these things should first be attended to. Should there be 
urethritis, that also should receive appropriate treatment. But the 
chief indication is to retain the urethra in place, and this may be 
accomplished by using the pessary which has been recommended for 
supporting the prolapsed bladder. Prolapsus of the upper part of 
the urethra can be remedied in this way quite satisfactorily. When 
the whole urethra is displaced this instrument, while it supj^orts the 
upper part, will still permit the middle portion of the urethra to 
settle down. This may be remedied by making the anterior portion 
of the pessary long enough to engage in the introitus vulvae, and in 
that way keep the whole canal where it should be. Should this 
cause the patient much discomfort the vagina may be tamponed 
with marine lint, and the parts kept in position until the trouble is 
partially overcome, and then the pessary will complete the treatment. 

LLLUSTEATIVE CASE. 

By way of illustrating what has been said on this subject, I will 
give the history of a case which may be accepted as a fair repre- 
sentative of such as will oftentimes be met in practice. 

A lady, fifty-seven years of age, who had borne seven children, 
and possessed excellent general health, was very much troubled by a 
partial loss of control over the bladder. While at rest she had no 
difiiculty, but on coughing, laughing, stooping, or lifting any heavy 
weight, the urine would escape in spite of her efforts to control it. 
I found the upper two thirds of the urethra displaced downward. 
Upon separating the labia, the urethra and vaginal wall presented 
just within the introitus, like the tumor seen in prolapsus of the 
anterior vaginal wall or cystocele. Introducing the catheter, I ob- 
served that it passed in the usual direction for about thi'ee eighths 
or half an inch, and then turned downward and backward, in the 



ORGANIC DISEASES OF THE URETHRA. 865 

direction of the hollow of the sacrum. I also satisfied myself that 
the urethra was not dilated, by observing that it grasped the catheter 
firmly throughout its whole extent. It was shortened to about an 
inch. This I ascertained by slowly passing the catheter until the 
urine began to flow, and then withdrawing the instrument and 
measuring from its eye to the point marked at the meatus urinarius. 

A pessary was fitted to keep the parts in place, and very marked 
relief was at once secured. 

From the nature of the dislocation, and the very prompt relief 
following the treatment, I am inclined to think that the incontinence 
in cases such as this is due to the settling down of the upper por- 
tion of the urethra, by which the pressure of the bladder and its con- 
tents falls directly on the sphincter vesicse, and overcomes its resist- 
ing power. Whether this is the correct explanation or not, one 
thing is certain, and that is, that cases like the foregoing are often 
met in practice, and the treatment of restoring the dislocated urethra 
gives prompt relief. 

It must not be supposed from what has been said about this case, 
that the partial loss of retentive power in the bladder so frequently 
met with in women who have borne children, is always due to dis- 
location of the urethra. The following case will illustrate sufiiciently 
well a class whose symptoms might lead to the suspicion of disloca- 
tion of the urethra when it did not exist : 

A lady, fifty-five years of age, the mother of six children, con- 
sulted me on the subject of her urinary troubles. She said that she 
was obliged to urinate oftener than she used *to, and that she could 
not stand or walk for any length of time without being annoyed by 
the dribbling of urine. 

She was rather out of health. Her digestion was labored, and 
she was anaemic and easily fatigued. Dislocation of the urethra 
was suspected, but upon examination the pelvic organs were all 
in proper position and free from disease, except that there was a 
want of muscular tonicity of the perinseum and vagina. The ure- 
thra was congested throughout its entire extent, and supersensitive, 
especially at its upper portion. There was also some slight dilata- 
tion, or abnormal dilatability, of the upper two thirds of the canal. 

She was treated with vaginal injections of cold water, applica- 
tions of tannin in solution to the urethra, and tonics, including small 
doses of nux vomica. As her general health improved, the urinary 
troubles gradually left her. This case properly belongs to the class 
of dilatations, but is given here to show its resemblance to that of dis- 
locations. 



DISEASES OF WOMEN. 

The failure (in certain cases) of all methods of treatment led me 
to devise the following operation for the relief of prolapsus of the 
urethra. An incision is made on each side of the urethra down 
through the vaginal wall, and extending from half an inch within 
the vulva upward and outward an inch or more. The edges of the 
wounds are retracted, and with a buried catgut suture the tissues 
below the vaginal wall are drawn together and at the same time 
united to the fascia which forms the subpubic ligament. Another 
row of sutures unites tlie deeper portion of the vaginal wall, and 
the third closes the surface portion of the wound. 

'No tissue at all is removed. The object of the operation is to 
gather together the tissues on each side of the urethra, and unite 
them to the fascia above. See Fig. 249a, Plate IV. . 

I am unable to speak from sufficient experience regarding the 
results of this operation, but it promises to be of great value. 

Prolapsus or Inversion of the Urethral Mucous Membrane. — This 
subject has been already spoken of in connection with urethral 
dilatations, and little more need be said about it, except to mention 
that it occasionally occurs as a distinct affection. In fact the mem- 
brane can not become inverted unless there is a change in its struct- 
ure and its relations to the tissues beneath it. Hence it must in all 
cases be a secondary affection. The membrane must be increased in 
extent of surface, either from relaxation of its fibers or hyperplasia, 
and its basic attachments be loosened, before it can be prolapsed. 
These changes are doubtless the result of malnutrition in the form 
of degeneration. 

The prolapse may be limited to one side, or extend all around the 
canal. The size and extent of the protrusion varies considerably. 
If the meatus is of full size, the prolapsed portion will usually pre- 
serve its natural color for a time ; but after a while, from chafing 
when wet with urine, and especially if not kept clean, it will become 
red and oedematous. When the meatus is small, these changes occur 
sooner and in a more marked degree, because the prolapsed portion 
is partially strangulated. 

The longer the membrane remains exposed, the more sensitive it 
becomes, and the frequency of urination and pain attending it in- 
creases. It also becomes very tender and painful to the touch. In 
marked cases the ordinary movements of the body irritate the parts, 
and in that way render walking painful. 

These are symptoms that closely resemble those of irritable 
growths at the meatus urinarius ; and, so far as history is concerned, 
it will not be possible to make a differential diagnosis. To do this it 



ORGANIC DISEASES OF THE URETHRA, 867 

is necessary to make a local examination. The physical signs, and 
the points in the diagnosis between this affection and other diseases, 
have been given briefly bnt sufficiently, under the head of dilatations 
of the urethra, and need not be repeated here. 

Prognosis. — This disease does not yield promptly to mild treat- 
ment, unless it is seen early in its progress ; and if it does yield to 
mild, soothing, and astringent applications, it is liable to return. 
But in case there is no other disease present that tends to keep it 
up, it can usually be cured by surgical means. 

Causation. — The causes of prolapsus of the urethral mucous 
membrane are numerous, but those that are best known are long 
continued congestion, urethral and cystic irritation, causing frequent 
urination, and vesical tenesmus. Chlorotic and greatly debilitated 
women are said to be predisposed to it, as also old prostitutes. The 
few cases that I have seen were in women over fifty years of age, 
and all of them were weak, nervous patients, who had suffered from 
some organic disease or functional derangement of the urinary 
organs. 

When a case is first seen it is well to remove any inflammation or 
other complicating conditions. The prolapsed membrane should be 
replaced, and the patient kept quiet in bed, to favor the retention of 
the parts in situ. Astringents, such as tannic acid, alum, or persul- 
phate of iron, in a mild solution, should also be used. Should these 
fail, resort must then be had to the operation for removal of the pro- 
lapsed portion of the membrane. The methods of doing this (by 
excision and the therm o-cautery) have already been described. 

It only remains for me to say that Winckel operates by clipping 
off the prolapsed portion of the membrane, and then stitching the 
internal edge of the membrane to the edge of the meatus with silver 
wire, allowing the sutures to remain in place for from five to seven 
days. If the operation is performed in this way the patient must be 
kept under observation, to see if contraction of the meatus takes 
place ; and if it does, it should be treated by dilatation. 



CHAPTER XLYIII. 

ORGANIC DISEASES OF THE URETHRA (cONTINUEd). 

STRICTURE, FOREIGN BODIES, AND INCOMPLETE FISTULA. 

8. Stricture of the Urethra. — Obstruction of the urethra, by nar- 
rowing of its caliber, is a much less common affection in the female 
than in the male ; still it occurs sufficiently often to demand atten- 
tion. There are some facts in the pathology of urethral stricture, 
peculiar to women, which I will first notice. Passing over congeni- 
tal narrowing of the urethra, by simply saying that such a malfor- 
mation has been seen, we find that stricture is developed in the 
female, as in the male, by the deposit of inflammatory products 
beneatli the mucous membrane, which by gradual contraction con- 
strict the canal. Ulceration of the membrane in a marked degree 
produces the same results. The inflammation and ulceration which 
end in the formation of stricture are usually specific in character ; 
but the same may follow from the too free use of caustics, and in- 
juries during childbirth. Stricture may also be produced by bands 
of scar tissue formed in the anterior vaginal wall and stretching across 
the urethra. Contraction of the whole canal occasionally occurs in 
cases of vesico-vaginal fistula of long standing. There the narrowing 
is simply the result of disuse. The form of stricture that will most 
frequently come under observation will be a contraction of the 
meatus urinarius, produced in many cases by the too liberal use of 
caustics in the treatment of abnormal growths at the lower end of 
the urethra, or from vulvitis. This form of stricture is the least 
troublesome, and is easily relieved. When due to the results of 
former urethritis or peri-urethritis, the walls of the urethra are 
thickened and indurated at the point of the stricture, and there is 
usually subacute urethritis, sometimes ulceration. In those cases 
where the cahber of the canal is diminished by cicatrices of the 
vaginal walls, and in general contraction of the urethra in vesico- 



ORGANIC DISEASES OF THE URETHRA. 809 

vaginal fistula of long standing, the mucous membrane may be per- 
fectly normal. 

Symptomatology. — Frequent and difficult urination are the chief 
troubles caused bj stricture of the urethra. The stream becomes 
smaller, and may be twisted or flat, but this is rarely observed. 
Patients, as a rule, only notice that they require to urinate more fre- 
quently and that they have to make more voluntary efforts to 
empty the bladder than were necessary before. It will also be found 
in almost all cases of stricture, that the subject has at some previous 
time suffered an injury at childbirth, urethritis, or something to 
which the origin of the stricture can be traced. Great care should 
be taken to obtain the previous history of cases in which stricture 
is suspected. This will aid in settling the diagnosis and causation. 

Diagnosis. — A digital examination by the vagina, will reveal 
thickening and induration, if the stricture is due to that cause. 
Cicatrices of the vaginal wall compressing the urethra can be de- 
tected in the same way. The use of the sound will aid in deter- 
mining the location of the stricture and the extent to which the 
canal is contracted. When the stricture is at the meatus it can be 
found with facility, and the size of the opening can be measured 
with equal ease ; but when it is located higher up, the largest sound 
that can be introduced without force should be passed up to the 
point of stricture. This will localize it ; then, by using a sound that 
will pass through it, the extent of the constriction will be ascer- 
tained. 

The affections which are liable to be mistaken for stricture are 
retention of urine or difficult urination from pressure on the urethra 
by the displaced gravid uterus, pelvic tumors, and dislocations of 
the urethra. The former can be excluded by a vaginal examination, 
and the latter can be detected by the sound, used as I directed while 
discussing the diagnosis of the dilatations. 

Prognosis. — Stricture of the urethra usually yields very promptly 
to treatment so that the prognosis is good. The only exceptions are 
where the stricture has existed in a marked degree long enough to 
cause dilatation of the ureters and disease of the kidneys. Chronic 
cystitis or urethritis occurring as a result of the stricture, or coinci- 
dent with it, may so complicate matters as to make recovery slow or 
even impossible. In cases where the whole urethra is contracted 
because of the existence of a vesico-vao:inal fistula of lono^ standino^, 
there may be found extreme difficulty in restoring the tissues of 
the urethral walls to their normal state. 

Treatment. — The treatment of stricture will depend upon its 



870 DISEASES OF WOMEN. 

location and cause. If it is situated at the meatus, it can be divided 
by the urethrotome, or forcibly stretched with the dilator. When 
due to bands of scar tissue in the vagina, they should be divided at 
several points, and the urethra dilated by passing the sound. When 
it is owing to deposition of the products of inflammation in the 
submucous tissue, forcible and rapid dilatation, as practiced on the 
male subject, will answer well if the proper cases for this form of 
treatment are selected. While operating in this way the dilatation 
should be made carefully, with a view to breaking up the constrict- 
ing tissue without lacerating the mucous membrane. To do this it 
is not necessary to dilate the urethra to any great extent. As soon 
as it is recognized that the stricture has given way, the dilatation 
should be suspended. 

Incising the stricture from within outward, according to the 
method commended by Otis and others, for the cure of stricture in 
the male, will no doubt answer a good purpose. In fact, I am in- 
clined to believe that this plan of treating the affection is the best ; 
but my own experience with this operation on the female urethra is 
not sufficient to warrant my speaking positively. 

In contraction of the whole urethra, arising from disuse in cases 
of vesico-vaginal fistula, gradual dilatation with graduated sounds 
answers yerj well. This should be attended to before closing the 
opening in the bladder. In all cases, attention should be given to 
any inflammation that may accompany the stricture or follow the 
treatment. It is well also to keep such patients under observation 
and pass the sound from time to time to see if there is any ten- 
dency for the stricture to return. 

Stricture at the Junction of the Urethra and Bladder. — I desire to 
direct special attention to this form of stricture because it is, so far 
as I know, peculiar to women, and its influence on the function of 
the bladder has not been pointed out. In fact, no distinction has 
been made between the pathology or clinical history of stricture at 
the upper end of the urethra and elsewhere in the canal. At least, 
lam not aware that writers on this subject have mentioned this 
form of stricture. My own observations on this subject have been 
limited, but sufficient, I think, to warrant me in saying that strict- 
ure does occur at the junction of the bladder and urethra, and that 
it behaves differently from ordinary stricture at other parts of the 
canal. 

From the study of th.e cases which have come under my notice, 
I have been led to the conclusion that stricture at this point may be 
produced by the causes which give rise to the same affection else- 



ORGANIC DISEASES OF THE URETHRA. 871 

where. The upper portion of the urethra is liable to the same trau- 
matic affections and inflammatory troubles as the rest of the urinary 
organs ; and the same products or results of disease which cause 
stricture of the other portions of the urethra act just the same at 
the point in question. I need not, therefore, dwell on the anatomi- 
cal lesions found in this affection. The point of most importance 
to which. I desire to call particular attention is the fact that stricture 
at this part of the urethra will cause difficult urination, which is 
out of proportion to the extent of the narrowing of the canal. In 
other words, thickening of the tissues at the union of the urethra 
and bladder, with contraction of the canal in a slight degree, will 
cause great difficulty in urination, and frequently retention. This is 
contrary to the history of stricture of the urethra at other points. 
In such cases there is no retention of urine until the stricture closes 
the canal, or very nearly so ; but I have seen retention in cases of 
stricture at the neck of the bladder while a medium-sized catheter 
could be passed with ease ; thus showing that the narrowing of the 
canal was not the only cause of the deranged function. It would 
appear that the change in structure of the tissues prevented the nor- 
mal action of that portion of the canal which performs the function 
of a sphincter vesicae. In discussing the anatomy and function of 
the bladder and urethra, I stated that the process of closing and 
opening the neck of the bladder was not fully understood, and I 
must acknowledge a like difficulty in explaining the disturbance of 
function whicb is caused by partial stricture at this point. Spas- 
modic stricture suggests itself as the explanation of the symptoms 
presented in such cases ; but it is excluded by demonstrating the 
presence of organic narrowing of the canal. 

Symptomatology. — The symptoms presented in tbis form of 
stricture are difficult urination, and in some cases complete retention. 
I have also noticed in one case that there was a frequent desire to 
urinate ; but that was accounted for by a slight catarrh of the blad- 
der. 

These symptoms are such as occur in other conditions, such as 
atrophy and paralysis of the bladder; obstruction of the urethra 
from tumors ; calculi ; or the pressure of the displaced uterus and 
prolapsus of the bladder. The affection can not, therefore, be de- 
tected from the phenomena presented. 

Diagnosis. — In this form of stricture there is thickening and 
induration of the neck of the bladder, which may be detected by 
digital examination of the vagina. The sound will also reveal a 
narrowing of the canal at the vesical neck, but the contraction may 



872 DISEASES OF WOMEN. 

not be marked. Main reliance must be placed upon the exclusion 
of all other conditions which can produce the same symptoms. 
Pressure upon the urethra and prolapsus of the bladder can be ex- 
cluded by an examination of the pelvic organs ; and the use of the 
sound will show anything Kke a complete obstruction of the canal. 

Having cleared away the possible existence of either of these 
conditions, I come to the two affections which are most likely to be 
confounded with tliis form of stricture, viz., atrophy and paralysis 
of the bladder. To distinguish these from the stricture, the cathe- 
ter should be passed when the bladder is well distended, and the 
character of the flow of urine watched, when it will be observed 
that in stricture the urine comes away with the usual force. The 
bladder contracts normally, and with its natural vigor, and expels 
the urine in a well- sustained stream through the catheter if there is 
stricture. On the other hand, in paralysis and atrophy, the stream 
is slow and without force, so much so that voluntary effort, or the 
pressure of the hand on the abdomen, is sometimes necessary to 
empty the bladder. This is especially so when the catheter is used 
while the patient is in the recumbent position. Finally, the diag- 
nosis is confirmed by testing the dilatability of the urethra. This 
can be done by passing a dilator along the urethra, and gently test- 
ing the resistance of the walls of the canal. In this way a slight 
yielding can be observed at all points until the stricture is reached, 
and then decided resistance will be encountered. By careful atten- 
tion to these points in the investigation, I believe it will be possible 
to make a diagnosis with reasonable certainty. 

ILLUSTRATIVE CASES. 

A lady, aged thirty-two ; man-ied fourteen years, and has had 
three children ; the eldest twelve years and the youngest four years of 
age. Thirteen years ago she had typhoid fever, and during the fever 
had retention of urine, which necessitated the use of the catheter 
for about two weeks. After recoveriug, she was able to empty the 
bladder without difficulty, but she suffered from frequent and pain- 
ful urination. After the birth of her second child, eight years ago, 
her bladder trouble became much worse, and she has been obliged to 
use the catheter almost daily ever since. When comparatively free 
from pelvic pain and tenderness (a relief that she seldom enjoys ex- 
cept for a few days at a time) she can empty the bladder by making 
strong voluntary efforts ; but the rule is that she is obliged to use 
the catheter about every four or Ave hours. The bladder and ure- 
thra were, upon examination, found to be in their normal positions, 



ORGANIC DISEASES OF THE UPwETHRA. 873 

but there were thickening and induration of the tissues at the union 
of the urethra and bladder. A l^o. 10 (Eng.) sound passed easily 
up to the neck of the bladder, where it was arrested. A No. 8 
(Eng.) sound was then used, and it entered the bladder after encoun- 
tering a little resistance at the point named. The catheter was then 
introduced, and the urine flowed freely and rapidly, the bladder con- 
tracting promptly and with its normal vigor. While the instrument 
was still in place, a vaginal examination by the finger was made, and 
the enlargement and induration of the urethral wall were distinctly 
felt. Dilatation of the urethra was then tried, and the canal yielded 
readily at all parts except at its extreme upper end, where it was 
found wanting in elasticity. There was slight catarrh of the blad- 
der, as shown by an excess of mucus in the urine. The urethra was 
also congested. The patient was very weak, nervous, and dyspeptic. 
She was put upon a course of tonic treatment, and the canal slowly 
dilated by passing twice a week graduated conical sounds, each one 
being allowed to remain in place for five or ten minutes at a time. 
She improved, but when last seen she still had difficulty in passing 
urine. 

Other cases might be given from my own records, but I prefer 
to present one, the history of which was given to me by Dr. Paul 
F. Munde. I do not wish it to be understood that the only difficulty 
in the following case was stricture ; I only desire to call attention to 
the fact that the patient had retention of urine and also stricture at 
the neck of the bladder. Still I am aware that the retention may 
have been due to some other cause — perhaps paralysis of the blad- 
der. There are some points in the history of the case which do net 
pertain to the question now under discussion, but I will give the full 
record in the doctor's own words : 

" Lizzie C, twenty-two years of age, single ; admitted to the 
Woman's Hospital, December 27, 1876. Menstruated first at twelve. 
The menses since have been irregular, amount small, and always 
with pain in back and hypogastrium, through whole flow of two 
days. General health always good until she had a 'bilious attack' 
six years ago. Four years ago the flow became more and more 
scanty, and finally ceased entirely three years ago, since which time 
she has not menstruated at all. Four years ago, after a ' bilious 
attack,' she had retention of urine for three days, at which time the 
catheter was used. She had several attacks of retention thereafter, 
at intervals, then micturated naturally for one year, but for the past 
three years has not been able to empty her bladder without the aid of 
a catheter, which she introduces herself habitually three times in the 
57 



874: DISEASES OF WOMEN. 

twentj-four hours. She lias no desire to micturate, and can hold her 
urine twentj-four hours without discomfort, save a slight sense of 
distention. She has leucorrhoea. Has slight menstrual molimina 
every four weeks, backache, hypogastric pain and soreness in breasts, 
constant pelvic weight and dragging. Bowels constipated. General 
health good. There is now frequent nausea. 

" Physical Examination. — There is anteflexion ; depth of the 
nterus, two and a half inches ; both ovaries prolapsed and tender ; 
right enlarged. 

" Treatment. — Hot vaginal douche, strj^chnia, benzoic acid ; later, 
daily washing out of the bladder with acidulated warm water (ac. 
muriat. dil., gtt. ij. to Oj). Urine contains a large quantity of mucus 
and triple phosphates. Washing out of bladder gives no relief. 
Phosphoric-acid mixture with ergot and iron was given for months 
with no benefit. Cups to lumbar region ; galvanic current through 
pelvis twice a week. 

"February 3, 1877. — Bladder washings omitted, as they caused 
pain. Large doses of ergot were given for two months (the strychnia 
being omitted after four months' trial), but without benefit. Faradic 
and galvanic current also used alternately every day for months 
without benefit. Discharged unimproved in any way. May 30, 
1877. 

"Keadmitted, October, 1877. Condition the same. 
"October 31. — Urethra dilated under ether; ^w^q^ introduced 
into bladder, which was found flaccid, and did not contract on the 
finger, which, however, was so closely constricted at the sphincter 
vesicae as to leave a circular ring on the finger, the distal portion of 
which appeared blue and almost numb on being withdrawn, after 
about ^\Q minutes. During the introduction of the finger the 
greatest amount of opposition felt was at the sphincter ; therefore, 
the supposition was expressed that the retention might be due to 
spasmodic contraction of the sphincter (hysterical probably, con- 
nected with and dependent on the amenorrhoea, or deficient pelvic 
innervation), accompanied by atony of the detrusor from the same 
causes. 

" On examining the pelvic cavity with the finger in the bladder, 
the left ovary was found normal in position, but smaller than it 
should be, being about the size of a shelled almond ; the right, how- 
ever, was distinctly felt as a globular body of the size of an English 
walnut. While practicing bimanual palpation on this ovary, it 
suddenly collapsed under the fingers and entirely disappeared, and 
could not be found on careful palpation. The explanation, doubt- 



OEGANIC DISEASES OF THE URETHRA. 875 

less, is that a cjst had been ruptured, and a partial cause at least for 
the amenorrhoea was thus discovered. Peritonitic symptoms were 
feared, and ice and opium given ; but, save some suprapubic sore- 
ness, no inflammatory reaction followed. Retention persisted, and 
urine had to be drawn the afternoon of the dilatation. 

''November 9. — Goodman's self -retaining catheter, with rubber 
tubing attached, was introduced for the purpose of allowing the 
urine to dribble ofE into a urinal, and thus give the bladder a chance 
to recover its tone. But the catheter caused so much pain that it 
had to be removed after several days. 

" E'ovember 19. — Soft-rubber catheter was introduced, with tub- 
ing, etc., for like purpose, and is now retained and on trial. This 
also caused pain, and was removed. Subsequently vaginal cystotomy 
was performed by Dr. Emmet, but without avail ; and the patient, 
after months of ineffectual treatment, was finally discharged un- 
cured." 

Treatment. — Regarding the management of stricture at the 
junction of the urethra and bladder, I am obliged to say that my 
experience has not yet been sufficient to enable me to speak definitely. 
It will be seen by the history of Dr. Munde's case that rapid and 
free dilatation is not sufficient to effect a cure ; at least, it did not 
relieve his patient. Division of the stricture by incision suggests 
itself, but I am confident that that operation would be unsatisfactory, 
becaase of the great irritation which always occurs when there is a 
solution of continuity at that point. My practice, therefore, has 
been to produce slow and gradual dilatation by the use of graduated 
sounds, and the application of oleate of mercury or iodine to the 
anterior vaginal wall at the site of the stricture. More extended 
observation may develop other and better methods of treatment, but 
for the present this is all that I have to offer on this subject. 

9. Foreign Bodies in the Urethra. — Having treated at some length 
the subject of foreign bodies in the bladder, I shall confine myself 
here chiefly to the practical points relating to foreign bodies in the 
urethra. The character of the bodies and their classification are the 
same as those given while discussing foreign bodies in the bladder. 

Symptomatology. — The chief symptom, if the body be of any 
size, is retention of urine. In some cases the obstruction is complete, 
in others the urine comes away in drops. In all cases there is pain 
and spasmodic action of both the bladder and urethra. If the body 
be rough or pointed, it will injure the urethral wall, and there will 
usually be hieinorrhage, and later, inflammation, possibly peri-urethral 
abscess. If not pointed, but hard and rough, it may ulcerate through 



876 DISEASES OF WOMEN". 

the urethral wall, causing considerable hgemorrhage. When tlie 
obstructioa is kept up for any length of time, the greatly distended 
bladder becomes very painful, and may be felt as a hard tumor 
above the pubes. 

If obstruction occurring from this cause be neglected, such in- 
juries of the bladder and kidneys as have already been described 
\vill ensue. 

Diagnosis, — The pain and retention will lead to the examination 
of the urethra, first by catheter or sound, and then by the finger in 
the vagina. In this way the foreign body is readily detected, un- 
less it be very soft, in which case it seldom produces retention, 
being usually washed out by the urine. 

Treatment. — The foreign body being detected, its extraction 
should be attempted first by seizing it with a pair of long-bladed 
forceps, keeping it firmly in place by a finger pressed on the 
urethra through the vagina behind it. If this is not successful, an 
attempt may be made to hook it out with a wire loop. 

I have seen calculi lodged in the urethra in two cases. The fii-st 
one was detected by using the catheter to relieve the retention of 
urine, and the other was felt through the vaginal wall, while ex- 
ploring with the finger to determine the cause of the pain in the 
urethra and the inability to pass water. 

The first one, which was lodged near the meatus, was removed 
as follows : The forefinger of the left hand was introduced into the 
vagina and pressed above the calculus to steady it. A v^re curette 
was then passed beyond the stone above, and by making traction 
with the curette and pressing with the finger from above downward, 
the body was extracted. 

The other was lodged higher up in the urethra and was removed 
by the same method, except that I used the alligator forceps instead 
of the curette. 

If it can not otherwise be reached the urethra may be dilated up 
to the point where the body is lodged, and then extracted. If ex- 
traction is impossible, there is a choice of cutting into the urethra 
and removing it, or of pushing it back into the bladder and then 
parforming lithotripsy. To me the former seems preferable. 

10. Incomplete Internal Urethral Fistula. — This is one of the 
rather rare affections, but it deserves a brief notice here, because 
little if anything, is said about it in the books, and it will be very 
likely met with at some time in the practice of every physician. 

The pathology is pretty clearly indicated by the name. It is 
simply an opening in the urethra which leads into the walls of the 



ORGAOTO DISEASES OF THE URETHRA. 87T 

nrethro-vaginal septum, but does not open into the vagina. It is 
the result of some pre-existing trouble. 

The causes which produced this affection in the cases which I 
have seen (I recall onlj two that have come under my notice) were, 
in the first, a peri-urethral inflammation which suppurated and dis- 
charged into the urethra, and in the second, a cyst which forjued in 
the urethro- vaginal septum, which also opened into the urethra. In 
the first case, I suspect that the patient had. gonorrhoea during preg- 
nancy, and that after confinement an abscess formed in the anterior 
vaginal wall, and opened into the urethra as I have already stated. 
The walls of the abscess contracted, but instead of healing com- 
pletely, there remained a sinus which communicated with the 
urethra. This much was inferred from the history obtained regard- 
ing its origin. When she was first seen, the fistulous opening was 
found in the floor of the urethra, and it led into the thickened and 
indurated septum between the urethra and vagina. 

The other case was developed under my own observation in the 
following way. The lady was pregnant, and during pregnancy 
observed that there was some enlargement just within the introitus 
vaginsBo On examination, a cyst was found in the anterior vaginal 
wall at the middle of the urethra. She was at the eighth month of 
utero-gestation when this diagnosis was made, and I decided to let 
the matter rest until her confinement. Immediately after the birth 
of her child, inflammation was set up in the cyst, and suppuration 
followed. An opening was made into the cyst from the vagina, 
and pus was freely discharged. At the same time pus began to flow 
from the urethra. The discharge continued from both openings 
for some time, and then the vaginal opening closed, but pus con- 
tinued to flow from the urethra for many weeks. A probe could be 
passed from the fistulous opening in the urethra into the sac, which 
slowly contracted, and finally, at the end of six months, closed en- 
tirely, and the patient completely recovered. 

Symptomatology. — There is pain during urination, and heat and 
aching distress in the urethra ; and if the opening is near to the 
neck of the bladder, frequent urination and vesical tenesmus. Pus 
is discharged from the urethra during urination, and is found in the 
urine. It also oozes away at all times. In some cases, the urine 
enters the fistula and causes smarting, burning pain during and foi* 
some time after urination, by distending the sac or burrowing in the 
tissues. 

Diagnosis.— YAXSimmmg the vagina by the finger will detect the 
thickening and induration of the walls of the urethra and vagina at 



878 DISEASES OF WOMEN". 

the seat of tlie fistula ; and bj making pressure witli the finger from 
above downward, pus and urine can be pressed out, and may be 
seen as thej escape from the meatus urinarius. A small probe with 
a bulbous point should be bent, so as to make a short curve at the 
end, and then passed into the urethra with the curve directed toward 
the floor of the canal ; and by moving it to and fro the fistula can 
usually be found. The point of the probe will catch in the open- 
ing, and when carried downward it can be felt through the wall of 
the vagina. 

The only condition which is liable to be confounded with fistula 
is urethrocele, but by keeping in mind the physical signs of that af- 
fection the distinction will be recognized. Should there be any 
doubt, the endoscope should be used to examine the urethra. The 
fistula mil then be found, and by using the speculum the opening 
can be probed through it. A flexible gum catheter may be used if 
the silver probe does not succeed. 

Treatment. — The cases that have come under my care were 
treated by washing out the urethra with warm water and borax sev- 
eral times a day, and keeping the sac emptied as completely as pos- 
sible by making pressure on the urethra, through the vagina, with. 
the finger. Both cases were very tedious, and required much care 
and long treatment. This experience has satisfied me that the man- 
agement of such cases ought to be altogether different from that 
which I employed. I am confident that better and ujore prompt 
results would be obtained by converting the incomplete into a com- 
plete fistula. This could be easily accomplished by passing a probe 
into the opening as far as possible, and then cutting down upon it 
through the wall of the vagina. By this operation a urethro-vaginal 
fistula is mads, which by proper treatment will close of its own ac- 
cord. During the after treatment the patient should wear a self- 
retaining catheter, or, what is still better, have the bladder emptied 
regularly by the catheter. This will keep the urine from getting 
into the fistula, which prevents healing. Care should be taken to 
keep the opening in the vagina from uniting before the urethral 
opening is healed. This can be accomphshed by passing the probe 
into it from time to time. The whole fistula should be kept clean 
by injecting water into the urethra and letting it fiow through the 
fistula into the vagina. In case the tissues are so indurated and 
changed in character as to refuse to heal under this treatment, the 
fistula must be closed by the usual operation. The method of oper- 
ating is the same as in vesico- vaginal fistula, a description of which 
will be hereafter given. 



CHAPTER XLTX. 

DISEASES OF THE GLANDS OF THE FEMALE UEETHEA. 

The diseases of these glands to which I invite attention are i 

1. Subacute inflammation or catarrh. 

2. Gonorrhoea! inflammation and its results or products. 

3. Inflammation following vulvitis such as occurs in strumous 
children. 

4. Tuberculosis. 

1. Catarrhal Inflammation. — The first affection named in the classi- 
fication is a mild form of inflammation which occurs in connection 
with subacute vaginitis, such as we find accompanying ordinary uter- 
ine disease, or following parturition. This condition gives the patient 
very little, if any, inconvenience, and readily passes unnoticed by the 
gynecologist unless specially looked for. The mouths of the ducts 
are slightly enlarged, and sometimes surrounded by a very narrow 
areola of a bright red color. By pressure upon the urethra from be- 
hind forward they discharge a white serous fluid. The cases which 
have come under my observation were detected while examining for 
other diseases, and none of them was attended with any marked 
symptoms. In some of them the inflammation disappeared without 
treatment. In others it continued without showing any tendency 
to increase in severity or lead to important changes of structure. It 
is quite possible that a non-specific vaginitis might induce a high 
grade of inflammation in these glands, with all the pathological 
changes to be described hereafter, but up to the present time I have 
not observed any evidence that such is the case. 

2. Gonorrhoeal Inflammation. — This is of the clironic purulent 
variety, and in time extends from the mucous membrane of the 
ducts to the surrounding tissues. It does not usually attract atten- 
tion until the vaginitis and urethritis have subsided. 

The lesions presented differ according to the length of time whicli 
the disease has existed. When examined early there is a slight 



S80 DISEASES OF WOMEN. 

swelling of the lower portion of the urethra. The mouths of the 
ducts are larger than normal, and the tissues around them are con- 
gested. There is tenderness to the touch, and pressure upon the 
urethra from above downward causes a free purulent discharge. 
Sometimes it is necessary to separate the labia of the meatus in order 
to see the orifices of the ducts. In cases of longer standing the 
mouths of the ducts are brought into view by a slight prolapsus and 
eversion of the mucous membrane caused bj swelling. The mucous 
membrane in the neighborhood of the ducts becomes thickened by 
proliferation of the areolar tissue and epithelium, presenting an ir- 
regular papillomatous appearance of a deep-red color, upon the inner 
sides of which the orifices of the ducts appear like minute ulcers, 
of a yellowish gray color. The lower third of the urethra is gener- 
ally thickened and indurated. The general appearance of the parts is 
quite like caruncle or papilloma of the meatus. In fact, inflamma- 
tion of these glands has been mistaken for caruncle, at least it has 
bsen my misfortune in the past to confound the two affections, and 
1 can not see how others could have made a differential diagnosis, if 
guided by the current literature upon the subject. In a large propor- 
tion of the cases of this disease I have observed that upou the inner 
sides of the labia minora, which rest upon the meatus, there are patches 
of inflammation which are caused and kept up by the purulent dis- 
charge from the glands. These circumscribed patches of inflamma- 
tion sometimes extend downward on each side of the introitus, and 
occasionally involve the carunculae myrtiformes. This gives rise to 
much tenderness, which simulates vaginismus. The chief symptoms 
are extreme tenderness to the touch, great discomfort in sitting and 
walking, occasional sharp stinging pain, and a continual sense of 
heat in the parts. There is painful urination in some cases, and in 
others there is not. In some of the most marked cases that I have 
seen, this symptom was entirely absent, while in less severe forms it 
has been present. That peculiar difference in the history of cases I 
have attributed to the fact that, in the well-developed forms of the 
disease there is a considerable eversion of the lower portion of the 
urethra, which throws the diseased and tender portion outward, and 
thereby prevents the urine from coming in contact with the irritable 
surfaces. Occasionally there is frequent urination, due probably 
to sympathetic irritation of the bladder. The symptom which is 
always present, in varying degrees of severity, is tenderness. The 
diagnosis and treatment may be left unnoticed until the other two 
affections of these glands have been described. 

3. Purulent Vulvitis. — This occurs in children, especially those of a 



DISEASES OF THE GLA:^TDS OF THE FEMALE URETHRA. 881 

scrofulous diathesis, and occasionally extends to the urethral glands. 
When such an extension of the disease occurs, it adds to its well-known 
rebelliousness to treatment. The original inflammation of the vulva 
mav be relieved, but if the glands are involved, the purulent dis- 
charge from them will soon light up the disease of the external 
parts. From my own observations I believe that these glands rarely 
become involved ; but when they do, there is little possibility of 
curing the affection of the vulva until the glands are first successful- 
ly treated. There is really nothing peculiar in the clinical history 
of this form of disease, except its etiology, and therefore I need not 
dwell longer upon it further than to say that I have seen a case of 
this kind, which had resisted treatment for a long time, but prompt- 
ly recovered after the inflammation of the glands was detected and 
treated. 

4. Tuberculosis, or Tubercular Inflammation of the Urethral Glands. 
— This is an affection to be distinguished from the other forms of the 
disease already considered. It occurs only in those who are of the 
tubercular diathesis, and may appear as a primary affection, or be 
developed during the progress of tubercular disease of other organs 
of the body. When the disease is first established, it presents the 
same pathological appearance as has been described under the head 
of gonon-hoeal inflanimation. There is, apparently, the same purulent 
discharge, with redness and proliferation around the mouths of the 
ducts, giving the peculiar caruncular or papillomatous appearance. 
The only peculiar characteristics of this affection that have been ob- 
served up to the present time, are the accumulation of caseous ma- 
terial in the tubules and ulceration, which occur in more advanced 
staq;es of the disease. 

The ulceration takes place in the newly-formed tissue in the 
walls and around the mouths of the tubules. These caseous con- 
cretions and ulcerations are not found in all cases. Indeed, they are 
rare. 

There is generally urethral inflammation accompanying this con- 
dition of the glands. It sometimes begins simultaneously with the 
disease of the glands, and when it does not it follows soon after. In 
time the bladder becomes affected, and also the kidneys. At what- 
ever point the disease commences it increases in severity, and ex- 
tends until the whole of the urinary organs are involved, unless the 
patient succumbs before it has completed its progress. In some 
cases there are polypi and papillary growths of small size found 
along the urethra. These, I believe, originate in inflammation of 
mucous follicles and papilla? of the mucous membrane. 



882 DISEASES OF WOMEi^. 

The symptoms presented in this form of disease are the same as 
those found in the other forms already described. From this it will 
be observed that the physical appearance and the symptoms are in- 
sufficient to establish a diagnosis. When there are ulcerations and 
caseous deposits the disease may be strongly suspected of being tu- 
bercular. Still, there is room for doubt until we find tuberculosis of 
other organs. This either precedes or soon follows the appearance 
of the disease of the glands. 

In all the cases which have come under my observation, the 
lungs were either tubercular when the patients were first seen or 
became so soon after. 

This affection is a source of great annoyance and suffering, and 
no doubt hastens the progress of the pulmonary disease, with which 
it is generally accompanied. It has also another very important 
significance in the fact that it indicates the commencement of gen- 
eral tuberculosis of the urinary organs. The diagnosis of tubercular 
cystitis and urethritis has always been exceedingly difficult in the 
early stages of the disease. Indeed, it has been deemed impossible 
by most authors to distinguish ordinary cystitis from the tubercular 
form until the disease became developed in other organs of the 
body. Now the tuberculosis of these glands is understood, a valu- 
able aid to diagnosis has been gained. Whenever an inflammation 
of these glands is found that can not be traced to a former gon- 
orrhoea or vulvitis, it is almost sure to be tubercular, and the 
diagnosis is placed beyond doubt if the patient has the tubercular 
diathesis. 

I am greatly indebted to Dr. Terrillon, of Paris, for some very 
valuable information upon the relations of disease of these glands 
to tuberculosis. In the " Progres Medicale " he published a very 
elaborate article entitled "Polypoid Excrescences of the Female 
Urethra, Symptomatic of Tuberculosis of the Urinary Organs," which 
is full of original observations of inestimable value. In comparing 
his observations with my own, I am fully satisfied that he has mis- 
taken tubercular inflammation, and the products of these glands, for 
excrescences, in some of his cases at least. Without being aware of 
the presence of these glands, it is perfectly natural that he should 
class those vascular developments found at the meatus urinarius 
among the ordinary neoplasms of the urethra, just as all others have 
done in the past. There is every reason for believing that the ex- 
crescences which Dr. Terrillon refers to difler in their essential pa- 
thology from the ordinary polypoid growths, usually called carun- 
culse, which are found in the urethra and are not associated with 



DISEASES OF THE GLANDS OF THE FEMALE URETRHA. 883 

tuberculosis. And as tlie history of his cases coincides with the his- 
tory of the cases of tuberculosis of these glands which I have seen, 
I am compelled to believe that he has not fully comprehended the 
true pathology of this affection. He has, however, clearly shown 
its relation to tuberculosis of the urinary organs, and that alone is 
worthy of the highest honor. 

Dr. Terrillon's article is too long to be given in full, but a few 
condensed extracts will show his views upon the subject. His 
description of the symptoms and the general appearance of the 
parts affected is so complete that I will give it in his own 
words : 

'' The fungoid growths show themselves usually at the surface 
of the urethral orifice. They are projecting and pedunculate. Sel- 
dom isolated, they form most frequently a wreath more or less regu- 
lar, around the orifice of the meatus. In very aggravated cases they 
are united into a mass, and then form a real projecting tumor with 
a fringed aspect, of a lively red. In the center of the tumor is easily 
to be found the orifice of the urethra masked by those papillary 
growths. The clinical history of fungoid excrescences of the urethra 
accompanying tuberculosis of that organ and the bladder includes 
the observation of two distinct parts : First, the study of the growths 
themselves and the character of them ; second, all the phenomena to 
be found in cystitis and tubercular urethritis. Sometimes the symp- 
toms of the two lesions are found together ; sometimes on the con- 
trary, they exist singly up to a certain period of the disease. One 
of the special symptoms of this affection is the exquisite tenderness 
of which these fungoids are possessed. The least touch, the least 
rubbing, the passage of urine, suffices to cause the most extensive 
pain, which renders life insupportable. This hypersesthesia, wiiich 
may extend to the neighboring parts, causes, at the sides of the ori- 
fice of the vulva, symptoms of the most acute vaginitis. These are 
the ordinary symptoms of fungoid growths when existing exter- 
nally." The author at this point refers to excrescences found 
within the urethra as being of the same nature as those found at the 
meatus. He makes no distinction between the two forms of disease. 
There is, however, a difference worthy of notice. Excrescences 
found within the urethra are usually cystic polypi or enlarged pa- 
pillae of the mucous membrane, conditions w^iich may exist inde- 
pen(Jently of tuberculosis. I infer from some other statements made 
in his writings that the granular urethritis — as we are in the habit 
of calUng it — is generally secondary to the disease of the urethral 
glands. The views of this author in regai-d to the order of develop- 



884 DISEASES OF WOMEN. 

ment of urethritis, cystitis, and finally tuberculosis of the lungs, are 
set forth in the following : 

"Sometimes at the time of their appearance these fungoids ap- 
pear to be altogether isolated from all other serious lesions. Yet 
they seem to precede tuberculization, or soon take a rapid course in 
developing granulations in the urethra. In other cases these growths 
may appear some time after the symptoms of tuberculization have 
been established." The cases recorded by Dr. Terrillon, and also 
those which have come under my own observation, show that, as a 
rule, this disease of the urethra precedes the appearance of tuber- 
culosis in other organs of the body, such as the lungs. It also is 
one of the first lesions observed in tuberculosis of the urinary organs. 
The following is from Dr. Terrillon's paper on this part of the sub- 
ject : 

"N'ow comes up the important question whether these polypi of 
the mucous membrane should be considered as a primary or an idio- 
pathic lesion, and I think that it can be solved in the following man- 
ner : These polypi are most assuredly the result of chronic inflamma- 
tion and an irritation of the mucous membrane. Now, development 
o-f tubercular granulations within the mucous membrane is at first 
the cause of irritation before any changes in the urine ; ulceration 
does not occur until after a sufficient length of time. With one of 
our patients the first irritation induced the formation of polypi, and 
the common painful symptoms followed. Their extirpation gave 
relief, but that lasted only up to the time when urethro- vesical ulcera- 
tion occurred. It will be observed that in this case the affection 
began in the urethra and extended to the bladder, and also second- 
arily involved the left kidney (ascending tuberculosis), causing, 
finally, change in the urine, with the free formation of pus. I there- 
fore do not hesitate to maintain that the fungoid polypi are the result 
of tubercular irritation of the mucous membrane of the urethra, 
which gives rise to the very serious symptoms which occur in the 
early stages of the disease. Without them, urinary tuberculosis 
would not give rise to those striking symptoms until after a sufficient 
length of time, when the ulcerations appear in other organs. An 
analogous phenomenon which is observed in the larynx should be 
mentioned here. We know, as a matter of fact, that the tuberculiza- 
tion of the larynx does not only occasion ulceration, but also poly- 
poid growths. There is produced at the expense of the ulcerated 
mucous membrane an hypertrophy and proliferation, in the form 
of cauliflower excrescences or cockscomb growths, a species of 
polypi, smaller or larger, by which the glottis might be more or less 



DISEASES OF THE GLANDS OF THE FEMALE URETHRA. 885 

obliterated. It will, therefore, be admitted that there is a resena- 
blance between laryngeal excrescences and those found in the ure- 
thra of women. The polypoid excrescences of the female urethra 
are shown, from an etiological point of view, to be of tw^o distinct va- 
rieties. The first variety is idiopathic, and may be recognized by a 
slight irritation. The prognosis is good; extirpation in these cases 
gives a rapid cure. This is the most frequent variety. The second 
kind, although they give the same outward appearance as the first 
variety, are, on the contrary, accompanied from the outset by ure- 
thritis and tubercular cystitis, of which variety these lesions consti- 
tute important symptoms." 

It is clearly evident to me that the two varieties described by 
Dr. Terrillon differ very essentially in their pathology. The first, 
or simpler forms correspond to the papilloma occasionally seen, and 
so easily cured by extirpation. The other variety has its origin in 
tubercular disease of the urethral glands, and is incurable by any 
treatment heretofore known, as the author states. 

Dr. TerriUon gives the full history of four cases observed by 
him. They are original, and of great value, but too long to be pro- 
duced here, Sufiice it to say, that in all four there were present the 
excrescences at the meatus urinarius, due, as their clinical histories 
show, to disease of the glands, and, finally, tuberculosis of the ure- 
thra, bladder, and lungs, A careful post-mortem examination was 
made in the fourth case observed, which revealed tuberculosis of the 
urethra, bladder, right kidney, and lungs. 

When I found inflammation of these glands associated with tuber- 
culosis of other organs, it occurred to me that the disease of the glands 
might be of the same nature, or tubercular ; but I am indebted to 
the writings of Dr. Terrillon for the full knowledge of the patho- 
logical relations of the affection of these glands to tuberculosis of the 
other urinary organs. We have studied the subject from different 
stand-points, and the combined results of our labors cover the ground 
pretty thoroughly. While he has clearly settled the relation of these 
excrescences to tuberculosis of the urinary organs, I have satisfied 
myself that these new growths are but the products of a tubercular 
inflammation of the urethral glands, the existence of which were, I 
presume, unknown to him. The treatment of the various forms of 
inflammation of these glands may all be discussed at the same time. 

It is settled upon the best evidence that when these glands be- 
come inflamed there is no natural tendency to their recovery. Those 
who have read the history of my first published case will remember 
that I employed all the recognized treatment for caruncle, but at the 



DISEASES OF WOME^. 

end of a year my patient was no better. Dr. Terrillon has had a 
similar experience. On this point he says: " A characteristic more 
important, and to which I desire to call esjDecial attention, because 
it indicates well, in my opinion, the consecutive development of these 
excrescences, is their tenacity and the facility with which they recur. 
Really, one can see in the observations" (meaning his cases) "in 
which continued surgical intervention has been practiced, it brought 
about either no relief or only a momentary amelioration." 

The treatment which I employed at hrst was to inject the tu- 
bules with the ordinary solutions used in the treatment of inflam- 
mation of mucous membranes, using for the purpose a hypodermic 
syringe, with the point of the needle rounded off. This method I 
found useful but very tedious. It then occurred to me that laying 
open the tubules their whole length and keeping them open would 
prevent the purulent accumulation (which acts so effectually in keep- 
ing up the inflammation), and also bring the affected parts within 
easy reach of the necessary treatment. This method was suggested 
in my paper, published seven years ago, and since then I have tried 
the method in quite a number of cases, and found it entirely satis- 
factory. In the majority of cases it is all that is required to effect 
a complete cure. The method of operating is as follows : The pa- 
tient is placed upon the left side, and a Sims's speculum used to keep 
the labia apart and retract the perinoeum. This brings the parts 
well into view, and within easy reach of the operator. 

The position and depth of the tubules having been first ascer- 
tained, the probe-pointed blade of a very fine scissors is then intro- 
duced, and the posterior wall divided its whole length. To prevent 
the parts from reuniting, a small piece of cotton, saturated with 
persulphate of iron, should be packed in between the divided edges. 
Brushing the surfaces over with the iron, without using the cotton, 
will answer, although less certainly, to prevent reuniting. Later 
still in my practice I have opened these ducts with the cautery. 
The method is as follows : A probe is passed mto the ducts, and the 
wall to be divided is made tense by making pressure outward with 
the probe. The tissues are then divided. This method has the ad- 
vantages of preventing hsemorrhage, and also of preventing the 
parts from reuniting. Yery little after treatment is required. In 
the majority of cases recovery follows the operation of laying open 
the canals. Sometimes the inflammation lingers in a modified form, 
but yields to a few applications of nitrate of silver or sulphate of 
zinc. In several cases in which the excrescences were abundant, 
they remained after the operation, although very much reduced in 



PLATE IV. 



FIG. 249 B. 
PAGE 887. 




SS^^^r^^^^'^'^^-^-^^'^ 



PLATE IV. 

Figure 249^*. Page 88V. 
Inflammation of the Urethral Glands. 

The hyperplasia of the niucous membrane about the mouth 
of the ducts is usually called caruncle. 

The red points about the vulva show inflammation caused 
bv the discharge from the glands. 



Figure 249a. Page 806. 
Operation for Prolapsus of the Bladder and Urethra. 

Incision on the lower side, and buried suture partly intro- 
duced. The line on the upper side shows the location of the 
incision. 



DISEASES OF THE GLANDS OF THE FEMALE URETHRA. 887 

size. An application of nitric acid destroyed tliem, and they have 
not shown the least disposition to return. 

ILLUSTRATIVE CASES. 

Gonorrhoeal Inflammation. — The patient was a married lady, thirty 
years of age. She was well developed, and had always enjoyed 
good general health. With the exception of a mild form of dys- 
menorrhoea, she had had no disease of the sexual organs until one 
year before she came under my observation. At that time she was 
abruptly attacked with a profuse leucorrhoea and other symptoms of 
inflammation of the vulva and vagina, including painful urination. 
She placed herself at once under the care of the family physician, 
who treated her locally until she came to me. Her leucorrhoea had 
by that time diminished, and the painful urination had passed away, 
but otherwise she had not improved. At my first examination I 
found traces of the former inflammation of the vulva and vagina. 
The meatus urinarius was everted and surrounded by a number of 
papillary projections, of a deep-red color, and altogether presenting 
an appearance resembling that which is known as vascular tumor, 
or carbuncle of the meatus. See Fig. 249^, Plate lY. 

The diagnosis then made was subacute vaginitis, perhaps of gon- 
orrhoeal origin, and inflamed papilloma of the meatus urinariuSo 
The vaginitis was treated in the usual way, and soon terminated 
in complete recovery, but the inflammation and tenderness of the 
meatus remained unchanged, and annoyed the patient exceedingly. 
She could not walk or sit without pain, and coitus had to be avoided 
entirely. 

I presumed at first that the disease of the meatus was kept up 
by the irritating discharge from the vagina, and I hoped that when 
the one was removed the other would get well, but such was not the 
ease. I then thoroughly cauterized the elevated and tender points 
about the meatus with nitrate of silver. This caused very great 
pain at the time, and was followed by no improvement. Pure nitric 
acid was used in the same way, but with no better result except to 
destroy elevations of the mucous membrane around the orifice. The 
same areola of inflammation around the meatus continued, and the 
symptoms remained the same. A full account of the progress of 
the case would be tedious and useless, Suflice it to say that for 
eight months I treated the disease with diligence and care, but at 
the end of that time she was very little better. 

Caustics and cauteries being unsatisfactory, I tried sedatives and 
alteratives, including iodoform, iodine, mercury, and bismuth. At 



88S DISEASES OF WOMEN. 

times the inflammation subsided slightly, and the elevated points 
became smaller, but in a short time fresh proliferations sprang 
up and the muco-purulent secretion continued to bathe the parts. 
Toward the end of this long period of treatment, and while making 
a critical examination, I observed that on each side of the meatus 
there w^ere two depressions tilled with a yellowish gray matter, look- 
ing like minute ulcers, but upon probing them, with a view to deter- 
mine their depth, I found that they admitted the probe over half an 
inch. After withdrawing the probe, I made pressure upon the ure- 
thra from above downward, and succeeded in expressing a purulent 
fluid, which could be distinctly seen escaping from their orifices. 
Treatment was then directed to these canals ; flrst, they were in- 
jected with tincture of iodine, and subsequently, they were cauter- 
ized by passing a probe coated with nitrate of silver along their en- 
tire depth. Prompt improvement followed this application. The 
inflammation around the meatus gradually subsided, and the pain 
and tenderness passed away. In less than two months from the time 
that a correct diagnosis was made and appropriate treatment em- 
ployed the patient recovered completely. The satisfaction which 
this gave to both patient and physician will be appreciated when the 
fact is recalled that she had been suffering for twenty-one months, 
and that for nine months she had been under my treatment without 
any marked improvement. 

Such was my experience with this disease before I knew any- 
thing about the presence and character of the structures involved. 
Since then I have seen several cases of the same kind, and have 
found the diagnosis easy and the treatment satisfactory. A brief 
history of another case will contrast agreeably with the former one : 

A delicate nervous lady, aged thirty-three years, married seven 
years without having had children. She had suffered for one year 
from symptoms resembling those of the case given above. At flrst 
her sufferings were not so severe, but in time they became intoler- 
able, and she was compelled to consult her physician, who exam- 
ined her, and found what he supposed to be a vascular tumor of the 
meatus urinarius. He sent her to me to have it removed, I found 
that she had the disease now under consideration, and a subacute 
vaginitis limited mostly to the upper and posterior portion of the va- 
gina. The inflamed papillae around the mouths of the ducts were 
deep red, and so tender as to render it very difficult to examine her. 
She was directed to use a vaginal douche of borax and warm water. 
The inflamed papillae were touched with equal parts of tincture of 
iodine and carbolic acid, and the ducts were injected with a solu- 



DISEASES OF THE GLANDS OF THE FEMALE URETHRA. 889 

tion of 3 ii of nitrate of silver to ^i oi water. Twice a week sub- 
sequently they were injected with a solution of two grains of 
nitrate of silver to the ounce of water, and finally borax and water 
were used. Under that treatment she recovered in six weeks. 

For injecting these ducts, I use a hypodermic syringe with the 
needle made probe pointed. 

The history of these two cases may possibly convey the impres- 
sion that inflammation of these glands is easily cured. That is only 
true in some cases ; I have seen others that were exceedingly obsti- 
nate. The disease would subside, but not fully disappear, and as 
soon as all applications were suspended would return. 

This has led me to think that other methods of treatment may 
yet be discovered, and has induced me to lay open the ducts of 
these glands in the way already described. 

Tuberculosis of the Urethral Glands. — The first case of this kind 
which I remember having seen came under the care of Prof. E. ^. 
Chapman at the Long Island College Hospital while I was his assist- 
ant. She presented at her first visit the history and physical signs 
of what was then supposed to be caruncle, which was treated with 
caustics. Yery little relief followed. She soon gave evidence of 
cystitis which was also treated for several months without success. 
The diagnosis was inflammation of the bladder. After a time she 
disappeared, but I subsequently learned that she died in the City 
Hospital, of pulmonary tuberculosis. Upon reflection I am satis- 
fied that the primary disease was tuberculosis of the urethral glands. 

The next case came under my own care in the Long Island Col- 
lege Hospital. When first seen she had papillomatous excrescences 
at the meatus and cystitis, presumed to be non-specific. I was at 
that time unaware of the presence of the urethral glands, and there- 
fore did not at first suspect tuberculosis. Treatment gave her no 
relief, and her sufferings were beyond description. In the hope of 
curing her, I made an artificial vesico-vaginal fistula, which relieved 
her very much, but her general condition became more and more like 
that of a consumptive. She died, and a post-mortem examination 
revealed complete destruction of the left kidney from tuberculosis. 
The bladder and urethra were covered throughout with tubercular 
ulcerations. Since I discovered the urethral glands I have seen two 
cases of tuberculosis affecting them. The history of one of them 
is as follows : 

A young single lady first consulted me for dysmenorrhea and 
frequent and painful urination. I found by examination that she 
had anteflexion of the uterus and inflammation of the urethral 
58 



890 DISEASES OF WOMEN". 

glands. The painful menstruation was partially relieved by correct 
ing the flexion. The inflamed glands were treated in the manner 
to be hereafter described, and the inflammation at that point disap- 
peared. Her frequent urination did not subside, however ; on the 
contrary, she developed a marked cystitis, which did not yield to 
treatment. Her lungs at the same time gave evidence of tubercu- 
losis, which proved fatal. 

Recurring Gonorrhoea from Gonorrhoeal Inflammation of the Ure- 
thral Glands. — Dr. H. C. Howard, of Campaign, Illinois, has re- 
cently had a series of cases in which gonorrhoea had been communi- 
cated by the husband to the wife, and cured in both, but repeatedly 
returned in the case of the husband, although he had not been im- 
properly exposed. Careful examination of the wife showed that 
the disease had persisted in tlie little glands of the female urethra, 
tirst described by Dr. A, J. C. Skene, of Brooklyn ("American 
Journal of Obstetrics," April, 1880), and fully noticed editorially in 
the " Chicago Medical Gazette," May 5, 1880. Dr. Howard, be- 
lieving that these little glands were continuing to pour out true 
gonorrhoeal pus, although the patient presented no other evidence 
of the disease, and that this pus had produced recurrent gonorrhoea 
in the male, directed his treatment to them, which consisted in the 
application of carbolic-acid crystals. In each case the discharge 
disappeared permanently under this treatment, and the disease in 
the male now having been cured, did not return. Dr. Skene in his 
original paper, expresses the opinion that in the case which he had 
observed, the inflammation was caused by gonorrhoea, which per- 
sisted in the glands long after the original trace of the disease had 
disappeared. Dr. Howard seems to have been the first to note this 
condition as a cause of gonorrhoea recurring as often as cured in the 
male. His observation is important as showing that the female may 
communicate the disease long after it would previously have been 
pronounced cured. — Chicago Medical Review^ August 6. 

After reading the account of Dr. Howard's cases I gave atten- 
tion to the subject and found cases to correspond with his. 

The following is a fair example and has additional value because 
confirmed by another observer. 

A widow who had children and was perfectly well, contracted 
a gonorrhoea which was supposed to be cured. She married again 
and her husband developed a gonorrhoea which he supposed was 
a recurrence of the disease, having had it before. He was led to 
this conclusion because his wife had no evidence of being simi- 
larly affected. He was treated by Prof. Charles Jewett and soon 



DISEASES OF THE GLANDS OF THE FEMALE URETHRA. 891 

recovered, but again and again the disease returned. Dr. Jewett 
suspected that his wife might have gonorrhoea without the usual 
acute symptoms. He sent her to me for examination. I could not 
find the slightest evidence of any disease of the urethra, vagina, or 
uterus, but I noticed that the orifices of the urethral glands were 
rather deeper in color than normal. To make sure I laid the ducts 
open, and found pus in both of them. They were thoroughly cau- 
terized with carbolic acid and tincture of iodine. From that day 
till the present time, now four years, there has been no further evi- 
dence of gonorrhoea in that family. 



CHAPTEK L. 

VESICAL AND UEETHKAL FISTULA. 

Classification and Pathology. — The classification of fistulge 
which I shall adopt is as follows : 

I. Yesico-Yaginal. — This is subdivided into {a) those occurring 
in the trigone, the opening being situated at the neck of the blad- 
der ; (5) those occurring at the bas-fond, the opening involving the 
inferior portion of the bladder. 

II. Ueethro-Yaginal. — The opening being between the urethra 
and vagina. 

III. Utero-Yaginal. — The opening communicating with the 
bladder, vagina, and cervix, or with the body of the uterus. 

lY. In this variety the entire vesico-vaginal wall is destroyed, 
and sometimes the urethro-vaginal wall also. This variety is for- 
tunately quite rare. 

The relative frequency of these varieties is about in the order in 
which they are given in the classification. The last and rarest one 
is attended with extensive destruction of tissue, and includes the first 
three classes. In fact, it covers the ground occupied by all the other 
varieties. 

The direction of these fistulse may be transverse, oblique, or 
longitudinal, and their form may be oval, round, linear, angular, or 
irregular. The dimensions of the opening also vary from one so 
small as barely to admit an ordinary probe to one measuring two 
inches in diameter. The direction of the fistula may possibly be 
determined by the cause of the primary injury. 

The form of the opening depends upon the arrangement of the 
muscular fibers of the vagina. This influences the line of laceration, 
and also the healing process, which latter modifies the final shape of 
the opening. 

The condition of the borders of the fistulse and their form differ 
much at first ; sometimes they are thin, inverted, quite pale, and 



VESICAL AND UEETHRAL FISTULA. 893 

smooth ; this is especially the case with the upper border. In other 
instances they are thick, soft, and muscular, or, again, they may be 
hard, inelastic, and ansemic. The mucous membrane of the bladder 
often projects through the opening if it is large, forming a red erect- 
ile tumor. 

Symptomatology. — The chief symptom is incontinence of urine. 
This is always the same, no matter how small or how large the open- 
ing may be. In some cases, indeed, this is the only symptom. In 
others there is much pain in the pelvic region, and irritation from 
the constant flow of urine, the pelvic pain being most marked at 
first, and in those cases in which there is much scar tissue. 

Sometimes there is inflammation of the bladder and urethra, 
which causes pain. 

If the fistula is due to parturition, the state of the bladder im- 
mediately succeeding the labor is such that for two or three days 
there is an inability to evacuate its contents without some pain or 
uneasiness, requiring perhaps the use of the catheter. After this 
the urine may escape through the urethra, or it may do so from the 
very beginning. 

In from five to ten days after confinement the urine begins to 
escape entirely from the vagina. A sense of something giving way 
is sometimes felt at that time. 

The labia, the inner surface of the thighs, and the peringeum, 
being constantly bathed in the urine, become red, inflamed, and cov- 
ered with pustules, which sometimes form ulcers of considerable 
depth. The external genitalia and the surface of the vagina fre- 
quently become incrusted with a saline deposit consisting of urates, 
and there is also a strong urinous odor about the person and the 
clothing of the patient. 

These symptoms and physical signs, while they are strong evi- 
dences of fistula, are not sufiicient to base a diagnosis upon. A physi- 
cal exploration of the parts must be made to ascertain with certainty 
the presence or absence of a fistula. 

Physical Signs, — The patient should be placed upon a table in 
Sims's position in a good light, Sims's speculum should be used to 
open the vagina, and the perinaeum should be drawn well back 
toward the sacrum until the entrance of the air distends the vaginal 
cavity. 

The fistula, if one exists, will most likely be at once detected, 
unless it is very small. If it is not found in this way, a probe should 
be used to explore any pockets or depressions that may exist in the 
vaginal wall. Should this fail, milk may be injected through the 



894 DISEASES OF WOMEK 

urethra into tlie bladder to distend its walls, and special attention 
given to see if any of it passes into the vagina. 

Incontinence from some muscular lesion of the neck of the blad- 
der, which allows the urine to find its way back into the vagina after 
escaping passively from the urethra, is the only affection which 
simulates fistula, but a careful examination made in the manner just 
described will determine the diagnosis. 

Complications. — These are stricture of the vagina, recto-vaginal 
fistula, obliteration of the urethra, and cicatrices of the vagina and 
cervix uteri. Inflammation of the edges of the fistula and deposits 
of urinary salts in the vagina may be present ; cystitis, vaginitis, and 
urethritis may also be found accompanying the fistulse. 

Prognosis. — If the fistula is of such a nature that it can be 
closed by an operation with any reasonable hope of success, and in 
the great majority of cases this is possible, the chances of a perfect 
recovery are excellent. 

Good operating will generally insure success, except in extraor- 
dinary cases, and these are very rare. 

Causation. — Pressure of the foetal head is the most common 
cause of vesico-vaginal fistula. Almost all authors agree in attribut- 
ing about ninety per cent to this cause. 

Compression of the soft parts in tedious labor causes death and 
sloughing of these tissues, and the edges of the opening thus made 
failing to unite, the fistulous opening results. If the vitality of the 
parts is not completely destroyed, but is greatly diminished, inflam- 
mation and ulceration may occur, and lead to the same result as in 
the case of sloughing. The best evidence that pressure of the foetal 
head in delayed labor is the chief cause of fistula is obtained from 
the fact that since the progress and improvement in the obstetric 
art, by which difficult labors are more promptly terminated, fistula 
is far less frequent than formerly. 

Wounds of the vesico-vaginal wall may occur during the use of 
instruments or long-continued efforts in manual delivery. The slip- 
ping of a perforator in cases of craniotomy may be especially men- 
tioned as likely to open the vesico-vaginal septum. 

The forceps have come in for a large share of blame in times 
past, but they have little agency in producing such an accident ; the 
earher and the more frequent that they are employed by educated 
hands, the fewer fistulae will occur. This is a fact obtained from 
the records of obstetrics and gynecology. 

Foreign substances in the bladder — vesical calculi, for example 
— may cause fistula by perforating the vesico-vaginal septum. Many 



VESICAL AND URETHRAL FISTULA. 895 

years ago I saw a case, witli Dr. J. H. Hobart Burge, of Brooklyn, 
in which this happened. The first calculus formed in the bladder 
was discharged through the vesico- vaginal septum, and several more 
were discharged through the fistula. Badly fitting pessaries, worn 
for too great a length of time, may also be mentioned among the 
causes inducing this lesion. Then there are a number of cases re- 
corded in which a pessary has destroyed the vesico-vaginal septum. 
The process by which the opening is made is no doubt ulceration 
from pressure and irritation. The process of ulceration is probably 
favored by the deposit on the instrument of the salts of the urine, 
and the irregularities of this deposit produce destruction of tissue. 
There is no doubt that this accident happened more frequently in 
past times when the material used for pessaries was unsuitable, and 
the methods of adapting them were not so well understood as they 
are now. 

The vesico-vaginal septum is often destroyed by malignant dis- 
ease in the advanced stages, but this does not belong to the subject 
on hand, and will not be discussed here. 

Treatmsnt. — The treatment of fistula is either palliative or cura- 
tive by surgical means. 

Palliative treatment is little more than an attempt to make the 
patient comfortable by protecting her from irritation and filth con- 
sequent upon the constant flow of urine. 

The curative treatment includes the preparation of the patient, 
the operation, and the subsequent management. 

Preparatory Treatment. — The operation for the cure of fistula 
should not be done until after the lapse of at least three months 
from the date of its occurrence. Some have operated earlier with 
success, but these early operations can not be expected to result suc- 
cessfully. It requires at least three months before the system has 
completely recovered from the influence of gestation and parturi- 
tion, and complete involution of the sexual organs is secured. 

In case of fistula the process of involution is apt to be delayed 
from the local irritation and general depression which usually attend 
such injuries. If the patient is feeble, with loss of appetite, and is 
nervous, months of preparatory treatment may be necessary, con- 
sisting of good diet, fresh air, attention to the intestinal and other 
secretions, with the use of tonics. 

It is certain that no one familiar with the treatment of this foi-m 
of fistula will be rash enough to subject his patient to the incon- 
venience of such an operation before attending to these preliminary 
measures. There is no operation in surgery which depends more 



DISEASES OF WOMEN". 

for its success on good general health than this one. As regards the 
local treatment, all inflammation must have subsided, and good gen- 
eral nutrition of the tissues about the fistula should be secured in 
order to give a fair chance to obtain union after the operation. To 
secure all this, due attention to cleanliness should be given and the 
vaginal douche of hot water frequently employed. The excoriation 
due to the urine flowing over the parts can be relieved by Lister's 
ointment of boracic acid. The saline incrustations which form on 
the edges of the fistula and other parts can be removed with the 
forceps, and their reformation can be checked by tonics, the min- 
eral acids being specially indicated. 

About one week after menstruation has ceased is the best period 
to operate. If it is delayed until near a menstrual period the anaes- 
thetic which must be given and the irritation produced by the oper- 
ation itself are liable to induce premature menstruation. Besides, 
the tissues are in the best condition to undergo the healing process 
at that time. 

The complication most commonly met with is stricture of the 
vagina and scar tissue at the edges of the fistula. No operation 
should be undertaken until these are disposed of as far as possible. 
The methods of relieving stricture of the vagina, and also of treat- 
ing scar tissue, are by dividing the cicatricial bands and dilating. 

For a fuller discussion of this subject the reader is referred to 
the section of this work on cicatrices of the cervix uteri and vagina. 

It may be remarked that in cases where the scar tissue can not 
be removed entirely, the best results are obtained by dilatation with 
the tampon. 

OPERATION FOR THE CURE OF FISTULA. 

An exceedingly interesting chapter might be written on the 
many methods suggested and practiced to close vesico- vaginal fistula 
but, while interesting, it would not be sufficiently profitable to oc- 
cupy time in this connection. It may be briefly, yet comprehen- 
sively, stated that all operations and all methods of treatment tried 
were failures until Dr. J. Marion Sims by his genius solved the 
problem. Furthermore, it may be stated that all modifications of 
Sims's method suggested and practiced by others have not been im- 
provements worthy of notice. A very few changes of a trivial 
character have been made which simplify some of the details of the 
operation, but beyond this the operation in principle and practice 
remains the same as when given to the profession by Dr. Sims, to 



VESICAL AND URETHRAL FISTULA. 897 

whom the world is indebted for this grand triumph of surgical 
science and art. In describing the operation I shall first give Sims's 
method as closely as I can, and then note such slight changes as 
have been made by other operators. I will be permitted to state here 
that before undertaking this important operation the surgeon should 
have acquired facility in the practice of Sims's methods of operating 
upon the cervix uteri and vagina. The placing of the patient in the 
proper position, the management of Sims's speculum when held by 
an assistant, and the use of gynecological instruments should all be 
familiar to the operator. The success of the operation involves so 
much to the patient, that all reasonable efforts should be made to se- 
cure success, and perfect operating is the first essential to that success. 

The treatment is divided into four parts : first, the placing the 
patient in the proper position and in a good light ; second, the par- 
ing the edges of the fistula ; third, the introduction of the sutures 
and tying them ; and fourth, the after management. The first pro- 
cedure is presumed to be familiar to the reader, but if not, refer- 
ence should be made to the chapter in which a detailed account of 
Sims's position is given and also the management of Sims's speculum. 
The operation is naturally divided into two parts — first, paring the 
edges of the fistula, second, passing the sutures and tying them. 

The patient having been placed in Sims's position upon the oper- 
ating table, and Sims's speculum having been introduced, one assistant 
holds the speculum while another does the sponging and assists with 
the instruments and sutures. A thoroughly competent physician 
should be secured to give the angesthetic. Very much depends 
upon the patient being kept perfectly quiet, and still free from the 
dangers of a too profound anaesthesia. 

Paring the Edges of the Fistula. — The lower edge of the fistula is 
seized with a Sims's tenaculum (Fig. 250), or a tissue forceps (Fig. 
Tl), according to the 
preference of the op- ^ 
erator. Then with a 

curved scissors (Fig. Fig. 250.-Sims's tenaculum. 

72), a strip is removed all around the fistula, extending from the 
mucous membrane of the bladder out upon the vaginal membrane at 
least three eighths of an inch (Fig. 251). Care should be taken not 
to wound the mucous membrane of the bladder. It is better to 
keep unbroken the piece that is removed if possible. If upon care- 
ful inspection there is any portion of the vivified surface that is 
not completely and uniformly pared, it should be trimmed until a 
perfectly smooth and beveled surface is obtained. Flo-. 251 shows 



898 



DISEASES OF WOMEN. 



the beveling of the vivified edges of the fistula. The paring should 
be done with a view also of making the edges of the fistula, when 




Fig. 251. — Operation for vesico-vaginal fistula: paring the edges. 

brought together, form a straight or slightly curved line. The 
direction of the line of coaptation will of necessity depend upon 
the size and long diameter of the fistula. When it is possible, I 
prefer to make this line correspond with the long diameter of the 
vagina, but in case the long diameter of the fistula is at right an- 
gles to the axis of the vagina, the edges must be brought together 
in that position. While the surgeon is paring the edges the assist- 
ant sponges the wound with sponges held in Sims's long-handled 
sponge-holders (Fig. 252.) 






Fig 252. — Sims's sponge-holder. 



When the scissors are used to do the paring there is not much 
haemorrhage. Occasionally there is troublesome bleeding which re- 
quires to be arrested by hot water either injected or applied with 
sponges. This will arrest all troublesome oozing, and if any vessel 
is found that persists in bleeding it can be closed by passing a cat- 
gut or silk suture under it from the vaginal surface some distance 
from the vivified edge. 

Introduction of the Sutures. — Dr. Sims employed silver-wire sut- 
ures in this operation, and by this he secured one great element of 
success. At the time that he introduced this metallic suture it was 



VESICAL AND URETHRAL FISTULA. 



899 





..-TXtMkWU a. CQ- 



the only one that was aseptic and without irritating quahties, both 
of which were absolutely necessary to secure union in the operation. 
Since that time a better knowledge of all that pertains to aseptic and 
antiseptic surgery has made it practicable to render silk as reliable 
as the silver wire. I have fully discussed this subject in the preced- 
ing pages, so that I need only say here that I use the silk in this 
operation. Long before I had given up silver-wire sutures, Simon, 
of Germany, had employed silk in operating for vesico-vaginal fistula, 
and with success. This fact, and my own experience, which has 
been just as favorable as when I used wire sutures, lead me to be- 
lieve that silk will be the suture of the future, and hence I will dis- 
cuss the exclusive use of it in this operation. That the silk is as 
successful as silver wire 1 have proved to my own satisfaction in many 
cases, and it is much more easily managed both in the introduction, 
tying, and removal. 
'No. 5 braided silk, or 
No. 3, if the walls of 
the septum are thin, 
prepared as heretofore 
directed, is used with 

Emmet's needle. The ^i^. 253.— Emmet's needles. 

length of the needle varies according to the thickness of the tis- 
sues to be sutured and the fancy of the operator. The needle is 
grasped in the forceps (Fig. 79), so that the two are at right an- 
gles, if the line of coaptation is parallel to the axis of the vagina, 
but, if the line runs across the vagina, the needle and forceps are 
arranged in a line. The tissues are held with a tenaculum, and 

the first suture is introduced at the 
angle farthest from the operator. 
The needle is carried through one 
side, and, when its point emerges, 
it is caught with Emmet's coun- 
ter-pressure instiTiment (Fig. 113). 
The first suture is then held by the 
assistant who holds the speculum, 
and this fixes the edges so that the 
other sutures can be passed with 
more facility. Fig. 255 shows the 
first sutures tied, and the others introduced. The majority of sur- 
geons introduce the suture about half an inch from the incision on 
the vaginal side, and at the edge of the mucous njembrane of the 
bladder. I much prefer to pass the suture in a curved line from 





Fig. 254. — The curved track of the needle 
b, bladder surface : v, vaginal surface. 



900 



DISEASES OF WOMEN. 



one edge to the other of the vivified surface (Fig, 254). If I find 
that this does not draw the surfaces together with facility, I pass 





Fig. 255. — Operation for vesico-vaginal fistula : the sutures in place : method of using 
the counter-pressure instrument in tying the sutures. 

half of the sutures a quarter of an inch back from the incised sur- 
faces, and then introduce superficial sutures between them to keep 
the edges from curving inward when the sutures are tied. 

The method of introducing sutures was 
fully described and illustrated in the chapter 
on injuries of the pelvic floor, but so much 
depends upon the accuracy with which this is 
accomplished that I refer to it again. 

The great point is to make the needle 
grasp more tissue in the central portion of 
the vivified surface than at the edges, so that 
when the suture is tightened the opposing surfaces will make two 
straight lines in place of two concaves, as would be the case if the 
needle was passed straight through the tissues. One can tell how 
the suture will tie by observing how the free surface appears when 
the needle is in place. When the needle is introduced completely, 
the tissues resting upon the needle should give a convex surface. 

The number of sutures to be used should be sufficient to bring 
the edges accurately together. This requires that they should be 
about three sixteenths of an inch apart, if ]^o. 3 silk is used. Hav- 
ing introduced all the sutures, the bladder should be thoroughly 
washed out, in order to free it from all blood that may have aecumu- 



FiG. 256 — Two sutures tied. 



VESICAL AND UKETHRAL FISTULyE. 901 

lated in it. Special care should be taken to make sure that no blood- 
clot is left in the bladder. The sutures should then be tied in the 
same manner as has already been described in the directions for 
restoring the cervix uteri after laceration. 

After Treatment. — The after treatment is very simple indeed, 
as I now conduct it. The patient is placed in bed, and, if there is 
pain of a severe nature, opium is given to relieve it. This is very 
seldom necessary, the pain being very slight, as a rule. During the 
first twenty-four hours the catheter is passed every four or six hours, 
and oftener if the patient has a desire to urinate ; after that, she is 
allowed to urinate when she desires to do so. If there is vomiting 
after the anaesthetic, sips of hot water are given. The tampon is 
removed on the second day, and the bowels are moved by enema on 
the third day. I keep the patient in bed, but, after the first twenty- 
four hours, she is permitted to change her position whenever that 
is necessary to secure her comfort, but she is not permitted to leave 
the recumbent position. On the eighth day the sutures are removed, 
and, if the result is perfect, the patient is permitted to gradually 
resume her usual duties. In some cases there is a slight cystitis, in- 
dicated by the presence of mucus in the urine and frequent urina- 
tion. This should be managed by v^ashing the bladder as directed 
under the head of the treatment of cystitis. 

The after treatment described above is nearly the same as that 
practiced by Simon, and I am satisfied that it gives as good results 
as any. It has also some great advantages. The patient escapes the 
great discomfort of wearing the catheter and remaining absolutely 
in one position, as she must do if the catheter is retained. There is 
also much less danger of cystitis or calculus if the catheter is not 
retained. Should any one feel disposed to use the catheter, I may 
say that Sims's new style, as figured on page 251 of Thomas's work 
on " Diseases of Women," is the best in general use. I have also 
employed a soft-rubber catheter, which is very comfortable. It is 
retained in the bladder by passing around it a piece of adhesive plas- 
ter, to which silk threads are attached and fastened to a strap carried 
around the waist. 

ILLUSTRATIVE CASES. 

The Simplest Form of Vesico- Vaginal Fistula. — In the winter of 
1886 my associate. Prof. Nilsen, brought a patient to my clinic, at 
the New York Fost-Graduate School, who had a bilateral lacera- 
tion of the cervix uteri and a vesico-vaginal fistula a quarter of an 
inch in diameter, located in the median line midway between the 
neck of the bladder and the cervix uteri. These iniuries resulted 



902 DISEASES OF ^OMEX. 

from her last confinement, which, was a very tedions one. The tis- 
sues around the fistula were in a perfectly liealthj condition. A 
tenaculum was passed through both edges of the fistula exactly in its 
center, care being taken not to include the mucous membrane of the 
bladder in the grasp of the instrument. Traction was then made 
with the tenaculum, which raised a cone-shaped projection in the 
vagina, the fistula being in the apex of the cone. While the parts 
were held in this position, the edges were pared with one clip of the 
curved scissors. The piece of tissue removed was oblong, with the 
fistulous opening in its center. The wound left was more than an 
inch long, and nearly three quarters of an inch wide on the vaginal 
side, while the opening in the mucous membrane of the bladder was 
not much larger than before. At the upper and lower angles of 
the wound, a little more tissue in the vaginal wall was removed with 
the tenaculum and scissors, and that completed the vivifying. Seven 
prepared silk sutures were introduced and tied, the bladder being 
first washed out, and the operation was completed. 

The lacerated cervix was then restored in the usual way. The 
two operations occupied less than an hour. The patient was then 
put to bed, and she rested fairly well during the night. About five 
hours after the operation, which was performed between eight and 
nine o'clock in the evening, the patient expressed a desire to urinate, 
and the nurse passed the catheter. After this the patient passed 
urine about every five hours for the first three days and nights, and 
subsequently at longer intervals. 

There was no other treatment except that the patient was kept 
in the recumbent position. At my next clinic, one week afterward, 
Prof. Xilsen removed the sutures from the fistula and cervix, and 
found the result perfect in both operations. When the sutures were 
removed there was scarcely a trace of the point of union where the 
fistula had been. 

Fistula complicated with Laceration of the Anterior Wall of the 
Cervix Uteri. (By T. A. Emmet, M. D.j — Ann Murphy, a native 
of Ireland, aged forty-one, was admitted to the hospital, October 5, 
IS 61, from the city. 

In May, 1857, she had been discharged cured from the hospital 
after an operation by Dr. Shns for the rehef of a utero-vesico- 
vaginal fistula resulting from a laceration directly through the 
anterior lip into the base of the bladder. Xine months after her 
discharge, she had a miscarriage at the third month, and a year 
afterward another at two months. 

In her second pregnancy, at full term, labor commenced by a 



VESICAL AND URETHRAL FISTULA. 903 

sudden rupture of the membranes on Tuesday evening, December, 
1861. Until 9 p. m. of the Thursday following the pains were 
slight and irregular. Labor then came on regularly, and within an 
hour afterward she was delivered naturally of a still-born infant, of 
the average size, with the feet presenting. The urine began to 
escape involuntarily after delivery. JSTo slough was passed, and 
she recovered as from a natural labor. 

Pathological Condition. — Laceration had again taken place along 
the line of the previous operation, through the anterior lip, directly 
in the median line. The fissure through the cervix had, however, 
closed nearly to the uterine canal, leaving a small fistula in the base 
of the bladder a few lines in front of the neck. 

October 5th. — The opening being so small, little more than its 
edges were denuded, and the raw surfaces were brought together 
with three sutures. On removing these an opening of about the 
same size was found near the cervix, leading forward into the fistula. 
In closing the fistula, a portion of the vaginal surface around the 
opening had been scarified, as well as its edges, for the purpose of 
increasing the breadth of surface brought together. As the opera- 
tion was so simple, either care had not been taken to pass a suffi- 
cient number of sutures to obliterate entirely the fold formed just 
in front of the cervix, on doubling the surfaces together, or else the 
sutures at this point had been twisted too tight, so as to cut out from 
below upward. 

October 30th. — For some distance around the opening the tissue 
was excavated with a pair of scissors, so that the surface was made 
to slope inward to the opening of the fistula in the bladder. The 
rest of the fistulous edge was then removed, as well as a portion 
of the cervix, and the old cicatricial tissue w^as got rid of by this 
means. But before these surfaces could be brought together, it was 
necessary to make an incision on each side to relieve the tension 
which would otherwise have existed. "When the surfaces were folded 
together, the line of union extended to such a distance beyond each 
extremity of the fistula that the fold thus formed was lost in the 
neighboring tissue. Nine sutures were used. The patient was dis- 
charged cured November 18, 1864. 

It is frequently more difficult to close a small fistula than to close 
one where a large portion of the base has been lost. On account of 
its size, the temptation is always great to remove simply the edges 
of the opening, instead of extending the scarification in the pro- 
posed line of union in the form of a long oval, so as to obviate the 
formation of the fold at each end. 



904 DISEASES OF WOMEN. 

This woman, about a year after her discharge, gave birth by a 
natural labor to her first living child. Some eighteen months sub- 
sequent to the operation she came with her child to see me. I 
made an examination for the purpose of ascertaining whether lacer- 
ation of the anterior lip had again occurred, and was pleased to find 
that the line of union was perfect. On passing a sound into the 
uterine canal, I was surprised to find a suture, which, from its 
length, I was unable to remove until it had been bent upon itself. 
It proved to be the one which had been passed nearest the os, and 
which by some means had been turned over backward into the canal, 
with its end in the direction of the fundus. The portion nearest to 
the fistula had become buried in the cervix, with over half an inch 
of the other end free in the uterine canal. She had given birth to 
her child, and the suture had remained for over eighteen months 
without its presence causing her any trouble. It has occurred to 
me that the remaining of this suture, which was passed deep through 
the neck on a line with the vaginal junction, may have been a for- 
tunate circumstance in preventing a recurrence of the laceration. 

URETHRAL FISTULA. 

Dr. Emmet has had the largest experience "svith this form of 
fistula, and has been, of all the surgeons I know, the most success- 
ful in its management. I regard him as the highest authority on 
this subject. 

The only fistulse of the urethra that I have seen have been those 
made by myself and others by urethrotomy. In my own cases the 
fistulse were made for the relief of dilatation of the middle third of 
the urethra accompanied by ulceration. The others were made for 
various purposes — one for the cure of cystitis, one for the purpose 
of making a diagnosis, and so on. At least this is according to the 
information received, taking the clinical history given in the htera- 
ture of the subject. There is nothing in the pathology or method 
of treatment of fistula in this location that differs from that of vesico- 
vaginal fistula. It is, however, very much less troublesome, there 
being no incontinence of urine unless the fistula involves the neck 
of the bladder, the operation for closing the urethral fistula being 
the same as in the vaginal fistula. 

There is no need of anything more being said on this subject. 
Cases of urethral fistula such as I have referred to would add noth- 
ing of value ; hence I shall give the history of the following case, 
which will illustrate urethral fistula caused by injury inflicted dur- 
ing labor. 



VESICAL AND URETHRAL FISTUL^E. 905 



ILLUSTRATIVE CASE. 

Fistnlse involving the TTrethra from Laceration or Sloughing. (By 
T. A. Emmet, M. D.) 

First pregnancy; the head born at the end of seventy-four hours; pains then ceased; 
body delivered fifteen hours afterward by traction. The urethra lacerated entirely 
through, half an inch from the meatus. The distal portion of the canal so dilated 
that a larire portion of the mucous membrane protruded. The difficulties of the 
operation consisted in passing the sutures so as to bring perfectly into apposition 
the two sections of the canal of different diameters. Operation successful. 

Mrs. H., aged eighteen, was admitted from Cold Spring, Long 
Island, April 27, 1867. She had been married two years, and had 
given birth to a still-born child. 

Labor at full term commenced Wednesday, January 24, 1867. 
The pains, however, were not very strong or frequent until the 
following Sunday. At 2 p. m. the head was born, but the pains 
entirely ceased afterward, and the body remained undelivered until 
Monday morning, when the labor was terminated by traction. 

Previous to delivery, the bladder had not been emptied for forty- 
eight hours ; four days afterward the urine began to dribble away. 
It was not noticed that any sloughs were passed from the vagina. 

Pathological Condition. — Directly across the urethra, about half 
an inch from the meatus, a fissure extended from one ramus to the 
other, dividing the urethral canal entirely through. The distal por- 
tion of the urethra was so dilated that the index-finger could be 
introduced for some distance within the canal. 

The mucous membrane anterior to the neck of the bladder pro- 
truded in a hj^pertrophied mass as large as an almond, resembling a 
prolapsed anus. In the center of the prolapse, the orifice of the 
canal just in front of the neck of the bladder remained undilated, 
and corresponded in diameter to the portion of tlie urethral canal 
through the anterior flap. 

This condition was an unusual complication, as the prolapsed 
mass filled up the sulcus, and, although it could easily be returned, 
it was with great difficulty kept within the canal for the purpose of 
scarification. The temptation was strong to remove a portion of 
it with the ecraseur, and wait until the surface had healed before 
operating ; this was, however, deemed unadvisable from the extent 
of cicatricial tissue, and the uncertain amount of contraction which 
would have resulted. 

Operation. — May 7th. — The whole extent of the sulcus was 
denuded around the edge of the urethra on each side with care, so 
69 



906 DISEASES OF WOMEN. 

as not to wound the mucous membrane of the canal. Thirteen 
sutures were introduced. 

The only point of interest was in regard to the manner of pass- 
ing those nearest the urethra. The sutures 1, 2, and 3 correspond in 
relation to their entrance and exit on the vaginal surface, IN^os. 2 and 
3 diverge from the edge of the undilated portion of the urethra 
to enter at a corresponding point on the margin of the dilated 
portion. 

Six sutures on each side, from the angles toward the urethra, 
were first twisted ; a large sound was then introduced into the blad- 
der to keep back the prolapsed portion while securing Nos. 2 and 3 
on each side of the urethra. Lastly, JSTo. 1 was twisted, but, before 
doing so, the slight prolapse was pushed back and kept from pro- 
truding by the point of a blunt hook passed under the suture, and 
retained until it was secured. 

On reflection, it will be evident that, in securing the sutures on 
each side of the urethra, they must necessarily approximate to a 
parallel course in relation to each other, and in so doing the excess 
of tissue would be rolled thus into the bladder. While the dilated 
outlet was doubtless folded somewhat on itself between the five sut- 
ures which embraced the diameter of the urethra, yet, as they were 
passed so as to bring the edges of the canal at each point into exact 
apposition, the catheter met with no obstruction, and the excess of 
tissue soon retracted. 

May 17th. — The sutures were removed, and the operation was 
found successful. 

May 29th. — A sound was passed along the urethra, and, after a 
careful examination, it was found impossible to detect the line of 
union, as not the slightest irregularity existed. The case was dis- 
charged by Dr. Emmet, cured, June 1, 1867. 

VESICO-UTEHINE FISTULA. 

In this variety of fistula the opening extends from the bladder 
into the uterus, usually into the cervix uteri. It is generally caused 
during labor, in which the anterior wall of the cervix is torn, and 
the laceration extends into the posterior wall of the bladder. 

During the healing which follows the injury, the lower portion 
of the wound in the cervix heals, leaving a fistulous communication 
running from the bladder into the canal of the uterus. The same 
fistulous opening may be formed in the operation for the purpose of 
closing the opening in the bladder, and at the same time restoring 



VESICAL AND URETHRAL FISTULiE. 907 



the laceration of the cervix. Union is secured on the vaginal side 
of the wound, but a fistulous opening, as described, is formed by 
the failure to obtain union in the deeper part of the wound. 

A case of this kind has already been quoted from Emmet. 

The chief points of interest in this form of fistula are in diag- 
nosis and treatment. The symptoms are the same in this as in all 
fistulae of the urinary tract, but the physical signs and diagnosis 
differ. No physical evidences of the presence of the fistula are 
obtained by examination with the speculum, except that the urine 
may be seen flowing from the canal of the uterus. If the urine 
does not flow at the time of the examination, the bladder should be 
filled with water colored witli carmine, which will escape through 
the canal of the uterus, thus proving the presence of the opening. 

To determine its exact location, and obtain some idea of its size, 
one sound should be passed into the bladder and another into the 
canal of the uterus, and by careful manipulation the points of the 
instruments can be made to meet. This will show where the open- 
ing is situated, and, by moving the sounds to and fro, an idea of the 
size of the fistula can be obtained. 

Treatinent. — The method of closing a fistula of this kind is to 
divide the cervix uteri and the vaginal wall down to the track of the 
fistula, and then pare the edges thoroughly, taking care to remove 
the scar tissue as completely as possible. Sutures are then intro- 
duced to close the entire wound in the bladder, vagina, and cervix. 

I believe that in this operation there is more likelihood of hav- 
ing troublesome haemorrhage than in vesico-vaginal fistula, but it 
can be arrested in the way already described. The following case 
will make the whole subject clear and complete. 

ILLUSTRATIVE CASE. 

A lady living in the country was delivered with forceps after 
having been in labor for forty-eight hours. When the forceps were 
used the cervix was not fully dilated, and the operator stated that he 
had much trouble in applying the instrument and delivering. She 
had incontinence of urine after her confinement. One year after- 
ward she came under my care. There was then a scar running 
down about three quarters of an inch in the vagina, from a partially 
healed laceration of the anterior wall of the cervix uteri. The urine 
could be seen flowing from the cervical canal. A sound passed into 
the bladder entered the canal of the cervix near the os internum, 
and could be felt with another sound in the canal of the cervix. 

The operation was performed by passing a sound through the 



908 DISEASES OF WOMEN. 

bladder into the canal of the cervix, and then, by cutting down 
through on each side of the scar tissue, a wedge-shaped piece was 
removed which exposed the track of the fistula. The edges of the 
fistula were then carefully pared, and the wound closed with sutures 
first introduced into the wound of the bladder and vagina, and then 
into the cervix. 

The catheter was kept in the bladder for five days, and at the 
end of the eighth day the sutures were removed, and the union was 
found to be complete. 



CHAPTER LI. 

DISEASES AND INJURIES OF THE URETEES. 

Injuries to tlie ureters during ovariotomy and hysterectomy are 
referred to in the description of these operations. The diseases of 
the ureters caused by various forms of cystitis are discussed in con- 
nection with diseases of the bladder. 

There still remain for consideration the injuries of the ureters 
which occur during labor, and ureteral affections caused by neo- 
plasms and other diseases of the pelvic organs. 

Affections of the Ureters due to Inflammation of the Pelvic Perito- 
naeum and Cellular Tissue. — Pressure from inflammatory products 
in the pelvic cellular tissue or on the pelvic peritonaeum may so 
obstruct the ureter as to cause hydro-ureteritis and pyelitis, and, in 
rare cases, fatal renal disease. In otlier cases the ureter may become 
inflamed from the inflammation of the tissues surrounding it. In 
that case obstruction and its consequences follow in natural order. 
The completeness and the duration of the obstruction appear to be 
most marked when the pelvic inflammation runs its course very 
rapidly and the exudate is large and extensive. 

Symptomatology. ^T}iQ indications of obstruction of the ureter 
are very obscure. The symptoms and physical signs of a cellulitis 
or peritonitis so fully command the attention of the observer that 
the ureter is very often overlooked. During the progress of the 
primary disease I have observed that the pelvic pain and tenderness 
extended up the tract of the ureter to the kidney, and that the dis- 
turbance of the digestive and nervous systems was more severe than 
jthe pelvic inflammation, uncomplicated, accounted for. From this 
it will be seen that I have, so far, been unable to observe anything 
iji the symptoms diagnostic of ureteral obstruction from this cause. 
; Physical Signs. — Products of inflammation may sometimes be 
found by an examination of the urine. All that I know of the 
physical signs of ureteral diseases and the methods of examination 



910 DISEASES OF WOMEN". 

I have obtained from the writings of Professor Howard A. Kellj. 
I will therefore quote from his article on this subject in the " Trans- 
actions of the American Gjnsecological Society " for 1888 : 

" By Ins2?ection. — Inspection is the method proposed by Dr. T. 
A. Emmet, and is conducted by splitting the vesico-vaginal septum 
and everting the edges of the wound until the ureteral orifices are 
exposed, when the ureters may also be catheterized, and their secre- 
tions compared. This method resembles the practice of introducing 
a catheter into the exposed orifices of the ureters in the margin of 
a vesico-vaginal fistula. It is one of value in serious cases warrant- 
ing operative interference ; nor is the operation, skillfully conducted, 
to be estimated as in any way grave. The edges of the incisions 
can be brought together after the examination, and the wound 
healed at once. 

'''By Catheterization. — The method of Professor Karl Pawlik, 
of Prague, of catheterizing the ureters free-handed, without prelimi- 
nary preparation of the patient, beyond the occasional distention of 
the bladder with a bland fluid, is the one deserving most attention. 
This method I have both practiced and seen at the hands of Pro- 
fessor Pawlik during the past summer (1888). The patient is placed 
in the dorsal position, with legs strongly flexed on the abdomen, 
and a Simon or Sims's speculum introduced, retracting the posterior 
vaginal wall. The eye at once observes a series of divergent folds 
starting just back of the neck of the bladder and sweeping laterally 
and back toward the cervix uteri, corresponding very closely at 
their point of union to the inter-ureteric ligament, and following in 
general outline the course of the ureters. A delicate catheter, a cut 
of which is shown at Fig. 257, is then carried into the bladder, dis- 



FiG. 257.— Kelly's Ureteral Catheter. 




tended with about four ounces of urine, and poised between thumb 
and index-finger. The position of the end of the catheter is plainly 
noted -by the eye, observing its movements in the vagina as the point 
sweeps gently along the floor of the bladder. The ureteral orifice 
is to be sought for about an inch back of the neck of the bladder, 
and about half or three quarters of an inch from the median line 
on either side. This position of the ureter, however, is not con- 
stant, and can not be relied upon alone. Far more characteristic is 
tJie slight tripping sensation given to the point of the catheter as it 
glides over the ureteral prominence. As soon as this sensation is 



DISEASES AND INJURIES OF THE URETERS. 911 

perceived, the catheter must be at once brought back to the place 
where it was felt, and gentle attempts made to engage its point by 
repeatedly carrying the handle upward and outward, and the point 
consequently in the opposite direction. Once caught, the catheter 
sweeps readily in, and, if lightly held, directs its own course, the 
fingers simply following. It thus passes some distance unrestrain- 
edly, parallel to the pelvic wall, and the eye observes the anterior 
vaginal wall being lifted up in advance and to one side of the cer- 
vix, forming a distinct pocket on the side on which the ureter is 
catheterized. This is a point to which my attention was specially 
called by Professor Pawlik. 

^' On withdrawing the stopper in the end of the catheter, a few 
drops of urine run out, when the flow ceases ; after a few seconds 
a few more drops run out, and then cease, keeping up in this way 
an intermittent discharge entirely characteristic. The catheter can 
not with safety be pushed beyond the brim of the pelvis. On with- 
drawing it the sudden drop of the anterior vaginal wall is very char- 
acteristic. I have found, as Pawlik states, that very slight force in 
the cadaver is apt to make false pockets in the mucosa of the blad- 
der. This was especially marked in a subject upon which I experi- 
mented this summer in Professor Yirchow's laboratory. The ureters 
were displaced backward to an extreme degree, and, in spite of the 
fact that I knew exactly where they were, and the catheter would 
constantly glide over the orifices, it was almost impossible to intro- 
duce it. I have at other times succeeded in introducing it at the 
very first attempt, and yesterday morning, in my office, catheterized 
the right ureter of a patient who did not know that I was doing 
more than making an ordinary vaginal examination. I have made 
a change in Pawlik's catheter, substituting a series of holes for the 
long fenestrum, which caught and cut the mucous membrane of the 
urethra in introducing it into the bladder. 

''^ By Palpation. — The finger is passed into the vagina be. 
hind the internal orifice of the urethra, at the end of the rugose 
promontory on the anterior vaginal wall, and carried with some 
exertion up toward the brim of the pelvis, displacing the vaginal 
wall upward and outward until the pulp of the finger reaches the 
highest point it can touch, often as high as the brim, Init varying 
according to the greater or less laxity of the tissues and their fixa- 
tion by pelvic pathological processes. It is then carried downward, 
stroking the pelvic wall, carefully estimating the character of all 
structures felt rolling under it. As soon as the observer thinks he 
has felt a ureter, he catches the cord again T\4th the hooked finger 



912 DISEASES OF WOMEN. 

and pulls it down a little, and then slides the finger first toward the 
bladder, where the ureter is felt to lose itself at the trigonum, and 
then backward, where it loses itself sweeping around the cervix. I 
have found that in a certain number of cases the ureter can be felt 
most distinctly in this position just in advance of the cervix, by 
placing the patient on her left or right side, when the vagina bal- 
loons out and applies itself closely to that side of the pelvic wall 
which lies undermost ; here the ureter can, by a slight effort dis- 
placing the vaginal vault upward, be hooked and brought down 
under the finger, felt with the utmost distinctness, and compressed. 

" By Bimanual Palpation. — I found, after examining a certain 
number of cases in which it was impossible to displace the vagina 
Bufiiciently to feel the ureter against the pelvic wall, or to feel the 
ureter with one hand lying like a cord in the connective tissue 
alongside of the vagina, that it was still possible to outline its whole 
course w^ith distinctness by a bimanual examination, when it could 
be picked up between the tips of two fingers and traced from cervix 
to bladder. In speaking of this to Dr. Sanger recently, he called 
my attention to the fact that he had mentioned the bimanual exami- 
nation, and stated that he was daily more fully appreciating its possi- 
bilities. The best position to feel for the ureters at the beginning 
of the bimanual examination is in the oblique diameters of the pel- 
vis, bringing the tips of the fingers as closely as possible together, 
and rolling them to and fro, keeping near the pelvic wall, watching 
for the characteristic sensation, when the cord may be traced in 
either direction. In late pregnancy, the ureters are especially dis- 
tinct, and seem often to be enlarged. Under favorable circumstances, 
a thickened ureter can be felt through the thin abdominal walls as 
it leaves the pelvis and crosses the brim." 

Treatment. — As a matter of course, the treatment must be chiefly 
directed to the primary inflammation which caused the obstruction 
of the ureter. 

I am satisfied that in many of the cases recovery takes place with- 
out any direct or specific treatment. Should the ureteral disease per- 
sist, relief may be obtained by catheterizing and dilating the ureter 
and washing it out with a mild solution of borax or sulphate of zinc. 

Obstruction of the Ureters by Uterine and Ovarian Neoplasms. — It 
may be stated here that the ureters become occluded most frequently 
in patients suffering from cancer of the uterus in its last stages. I 
have seen several such patients die from urgemia. There is but little 
that can be done for their relief, and hence nothing more need be 
said on this subject. 



DISEASES AND INJURIES OF THE UPwETERS. 913 

Obstruction of the Ureters due to Uterine Fibromata. — I have sev- 
eral times seen this condition. The symptoms are, pain on the 
affected side (one ureter only is obstructed, as a rule); the pain 
extends upward in the Hne of the ureter to the kidney, a dull, aching 
pain in the back on that side ; there is usually tenderness on press- 
ure, and often a slight sensitiveness on bimanual examination of the 
kidney on the affected side ; by that I mean, when one hand is 
placed on the back and the other on the abdomen, and pressure is 
made over the kidney with both hands. Digital examination of the 
vagina reveals nothing of value except tenderness. The treatment 
in this condition must largely be directed, as in obstruction from 
other causes, to the neoplasm that gives rise to it. If the fibroid is 
impacted in the pelvis, efforts should be made to raise it up into the 
abdominal cavity. Electricity should be employed in mild cases ; 
but when there is danger, and relief is not obtained, hysterectomy 
should be resorted to. Indeed, I consider this as one of the most 
important indications for the removal of the uterus. 

ILLUSTRATIVE CASES. 

Obstruction of the Ureter from Pelvic Cellulitis. — The patient suf- 
fered from menorrhagia ; a sponge tent was used to dilate the cervix, 
after which curetting was performed. This was before I knew how 
dangerous and useless such tents were, and before antiseptic surgery 
was fully practiced and taught. The result was a circumscribed cel- 
lulitis on the left side. About the fifth day the constitutional symp- 
toms increased decidedly, and the pain extended upward on the left. 
There was difficulty in urinating, and the catheter was used. The 
urine was at first clear, but rather abruptly became turbid. This 
led to an examination which showed the presence of pus. I sup- 
posed that a cystitis had been caused by the use of the catheter, but 
further investigation proved that the pus came from the ureter and 
kidney. The case was under observation at the time when I was 
learning how to tell when pus or blood, that was found in the urine, 
came from the bladder or kidney ; and, on that account, I made a 
number of examinations, all of which indicated that the trouble was 
in the ureter and pelvis of the kidney. A friend, who also ex- 
amined the urine, made the diagnosis of pyelitis and acute nephritis. 
The cellulitis ended in resolution, and the patient recovered and has 
remained in good health. 

Obstruction of the Ureter from Uterine Fibroma.— A lady fortv- 
three years old, who had a very large uterine fibroma which she had 
carried for years without being much embarrassed by it, wa^ taken 



914 DISEASES OF W0ME:N'. 

with backache and some ill-defined constitutional symptoms, which 
for the first time compelled her to give up her duties to a great ex- 
tent, but she did not seek medical aid. She died suddenly, after a 
convulsion, which was not very well described by the friends who 
were with her at the time. In fact, there was no clear history ob- 
tainable. Post-mortem, I found a large fibroid, and in the cellular 
tissue around the upper part of the cervix uteri there was much 
oedema, and what looked like an exudation. Both ureters were 
dilated, and there were hydro-nephrosis and acute nephritis. All 
the other organs of the body were normal. 

Injuries to the Ureters during Labor. — T\"hile engaged in obstetric 
practice, both hospital and private, I attended several cases which 
differed from any of the puerperal diseases recorded in obstetrical 
literature. 

During the early years of my investigation very httle was learned 
about these cases except that there was something in their pathology 
which was not known to me. The manifestations of the affection, 
as observed clinically and at post-mortem examinations, led me 
eventually to infer that injury to the ureters during parturition was 
the cause of the phenomena which I witnessed in these cases. 

Pathology. — From a considerable study of the subject clinically, 
and a meager one of its morbid anatomy, I feel warranted in stating 
that the pathology of this affection is a contusion or laceration of 
one of the ureters by the head of the child, the hand of the obstet- 
rician, or more often by the forceps. This contusion gives rise to 
swellino: of the walls of the ureter and the cellular tissue around 
it, and perhaps some degree of inflammation. This is sufficient to 
obstruct the ureter and cause hydro-nephrosis, and subsequently pye- 
litis. As the swelling, and perhaps inflammation, at the point of 
original injury subside, the pressure of the urine and pus above 
forces a way through the ureter, and relief follows. This is the ex- 
planation of the sudden discharge of pus with the urine. In case 
the obstruction lasts long, the kidneys become involved to an extent 
that varies according to the duration of the obstruction. "Whenever 
the ureter is completely blocked and remains so, there is nephritis, 
and then acute uraemia, which may prove fatal, as already stated. 

In a given number of cases, there are some in which there is cys- 
titis, but no marked disease of the kidneys. In others, the bladder 
is not involved, but the kidney is ; while in others all three organs — 
bladder, ureter, and kidney — are affected. "When, as is not infre- 
quently the case, there are some of the usual injuries of the cervix 
uteri and pelvic floor, and metro-cellulitis follows, the ureters become 



DISEASES AND INJURIES OF THE URETERS. 915 

secondarily affected. Under sucli circumstances the order of de- 
velopment of the pathological lesions is reversed to some extent, and 
hence the clinical history is changed, so that the ureteral obstruction 
and consequent renal disease come later and generally are less dan- 
gerous, owing to being less acute and of shorter duration. 

Ca\isation. — Predisposing Causes. — There are certain conditions 
which predispose to injuries of the ureters during labor. When the 
bladder and terminal ends of the ureters rest low in the pelvis toward 
the end of gestation, there is more liability of their being cauglit 
between the child's head and the brim of the pelvis during labor. 
In many cases the ureters suffer some impairment of nutrition dur- 
ing gestation (and are more susceptible to injury) that is produced 
by passive hypersemia and oedema, and hence a softened state of the 
pelvic tissues follows. There is in such cases a want of elasticity 
and resistance to injury. This is seen in the friable condition of the 
cervix uteri, vagina, and pelvic floor, which renders them so easily 
damaged. In brief, then, the location of the bladder and ureters, 
the pre-existing lesion or functional derangement of the ureters, and 
malnutrition of the tissues in the pelvis, are the conditions which 
predispose to graver injuries during labor. 

Direct Causes. — The fact that the ureters escape injury when 
dilatation of the cervix uteri is complete before expulsion proceeds, 
gives a clew to the causation of such injuries. When the mem- 
branes rupture before dilatation is complete, and consequently the 
cervix uteri and bladder are carried down into the pelvis before the 
advancing head, the ureters are exposed to undue pressure and 
traction also, and hence are sure to be more or less injured. The 
dangers are much greater when it is necessary to use the forceps or 
perform version under these circumstances. The presence of hard 
faecal matter in the rectum may also be mentioned among the causes. 
Faulty methods of operating no doubt add to the dangers. Undue 
lateral motion of the forceps during extraction must certainly do 
more or less damage to the adjacent tissues and ureters. Especially 
is this likely to occur if the cervix uteri and bladder are permitted 
to descend before the advancing head. 

Symptomatology. — The patients are usually primiparre, or at 
least have not had many children, the labor tedious, instrumental or 
manual, and the progress after delivery fairly satisfactory for several 
days. The lochial discharge may be normal, and the secretion of 
milk also. The bowels may act well, and the kidneys apparently so. 
In some patients there is retention of urine or frequent and painful 
urination. Pelvic pain and tenderness in the lower part of the 



916 DISEASES OF WOMEN. 

abdomen are present, but are not always severe at first. These 
symptoms become more acute after a time, the pain and tenderness 
increase rather abruptly, and a chill or rigor may occur ; distention 
of the bowels takes place, the temperature runs up, and the pulse is 
also increased in frequency. 

An increase in the severity of the symptoms supervenes in from 
three to five days, and soon thereafter a quantity of pus, and some- 
times blood, appears in the urine. When the discharge of pus 
begins, the patient is generally relieved to some extent. The pain 
is less, and the temperature and pulse are reduced a little. In con- 
nection with pus and blood renal casts may be found, but this is not 
invariably the case. The pus continues to be discharged in dimin- 
ished quantity for a week or more. The bleeding generally subsides 
in a day or so, and most of the cases gradually recover. In others, 
acute disease of the kidney appears about the time that the pus be- 
gins to be discharged from the bladder, and ureemia follows, and 
sometimes ursemic coma. Such cases end fatally, as a rule, but I 
have known one to recover. 

Physical Signs. — There is tenderness to the touch along the 
line of the ureter, and bimanual manipulation of the kidney upon 
the affected side usually causes a sense of distress rather than 
pain. In uncomplicated cases a vaginal examination gives nega- 
tive signs, except that tenderness is detected high up on the side 
involved. 

The diagnosis of injuries of the ureters must be made by the 
exclusion of the more common puerperal affections, such as peri- 
tonitis, cellulitis, or general septicaemia. Metritis is excluded on 
the grounds that the lochia are normal, that there is absence of ten- 
derness, and that involution progresses as it should. The sympto- 
matic fever is too mild in character to indicate general peritonitis, 
and the physical signs of that affection are wanting. The tenderness 
on pressure on the side affected, and the constitutional disturbance 
not otherwise accounted for, are suggestive of cellulitis, but the evi- 
dence, so far as relates to physical signs, of tliat affection is insuffi- 
cient, and the subsequent history effectually excludes it. 

The sudden appearance of pus and blood in the urine leads one 
to suspect that an abscess has formed in the cellular tissue and dis- 
charged into the bladder. This condition is excluded on the ground 
that there have been no physical signs of cellulitis; and, further- 
more, an abscess never discharges into the bladder in so short a time 
after the inception of pelvic cellulitis. 

In cases complicated with traumatic cystitis, it might be pre- 



DISEASES AND INJURIES OF THE URETERS. 91Y 

sumed that an abscess had formed in the wall of the bladder ; but 
that is excluded for the reason that the violent symptoms and physi- 
cal signs found in traumatic and interstitial cystitis are absent. In 
short, the history of injury to the ureters differs from that of all 
the puerperal diseases hitherto described in medical literature, so far 
as I know. 

Preve?itw7i.— These injuries being difficult to manage, their pre- 
vention is of prime importance. When the presence of renal 
trouble is detected before labor, and it is presumably due to partial 
obstruction of the ureters, much may be done by rest in the recum- 
bent position, and the judicious use of cathartics, diuretics, and vaginal 
douches. By improving the circulation and general nutrition of the 
organs and tissues, the existing ureteral trouble may be relieved and 
further injuries avoided. During labor much may be accomplished. 
Full dilatation of the cervix before rupture of the membranes, so 
that the bladder and ureters may rise out of the pelvis when the 
head descends, insures comparative safety. In view of these facts 
the judicious obstetrician, being fairly conscious of the danger to 
the ureters, will find an additional reason for looking after their 
interests.. 

My attention was first given to this matter in order to save the 
bladder from contusions and displacements, and later I found that 
this was one of the surest w^ays of saving the ureters also. 

I have many times called attention to the necessity of supporting 
the bladder during labor, and indirectly the ureters also, but so much 
attention is bestowed upon management of the perinseum, that the 
more important dangers to the urinary organs are very largely 
ignored. This supporting of the parts during labor should be more 
carefully watched when delivery with forceps is practiced. 

Lacerations of the cervix uteri and pelvic floor are unfortunate 
complications, but they do not compare with injuries of the ureters 
in gravity of results. The fact is, that the possible danger to the 
ureters has not occurred to obstetricians, as a rule, but when fully 
appreciated will have due attention. The lateral motion of the for- 
ceps, referred to, is happily not necessary, nor is it practiced by 
experts, I believe; still it should be avoided, for the sake of the 
ureters as well as for the reasons given in obstetric works. This 
would be an uncalled-for statement, were it not for the fact that 
while the science of obstetrics is most mature, and the art is practiced 
by the few in a perfect way, yet the practice of the many is often 
insufficient, to say the least. 

Treatment. — The management of injuries of the ureters which 



918 DISEASES OF WOMEN. 

have occurred is, I fear, in a very immature state. At least, I have 
never read or heard of any suggestion regarding treatment, and can 
only give the results of personal observation. 

Being without precept or example, and for years not knowing 
the pathology of the cases under observation, I treated them as in- 
flammatory affections, without special regard to the location and 
character of the inflammation, for they were unknown. When a 
clear comprehension of the nature of the affection was obtained, the 
treatment was still rather expectant. There is one thing which has 
appeared to be of advantage, and that is, keeping the bowels free. 
In fact, free catharsis may be tried if the patient is able to stand it. 
This I discovered by seeing a case in consultation, in which the at- 
tending physician, suspecting septicaemia or obscure peritonitis, had 
adopted the modern treatment — saline cathartics. The results were 
good, and I feel confident that it is a useful treatment. When the 
bladder is involved, much is gained by washing it out repeatedly ; 
this relieves the pain in the ureter and kidney to some extent. 
Retention of the urine for an unusual length of time increases 
the suffering, and no doubt also the traumatic inflammation. The 
catheter does much good if used by a skilled nurse or obstetrician. 
The unclean metallic catheter, in general use when I first observed 
such cases, always did harm. Hot vaginal douches have been tried, 
and when they relieve pain they are curative ; but when they increase 
the suffering at the time of their use, or immediately after, as is 
often the case, harm may result. In a word, the treatment has been 
to relieve pain, sustain the patient, and trust that the damages would 
be repaired before the kidneys were fatally involved. The question 
of surgical treatment has occupied some time and thought, without 
my arriving, however, at any definite conclusions. 

Catheterizing the injured ureter seemed to be indicated, but I had 
had no experience with it in acute injuries, because I gave up ob- 
stetrics about the time that the practice of catheterizing the ureters 
was introduced, and I had not acquired facility in the operation ; 
and, lastly, I doubted the safety of such treatment, and felt that it 
should be tried by an expert first, if at all. 

In the class of cases due to inflammation of the tissues around 
the ureter, the use of the catheter, in the hands of an exj)ert would 
be of the greatest value. This has been proved by Kelly, Engel- 
mann, and others. But when the ureter is the primary subject of the 
injury, it is doubtful whether catheterization would be possible, and 
there would be much danger of the instrument perforating the 
ureteral wall. 



DISEASES AND INJURIES OF THE URETERS. 919 



ILLUSTRATIVE CASE. 

The history of this patient, from the time of her confinement 
until her death, was characterized by the symptoms and signs which 
are given above. 

The patient died two weeks after confinement, and, post-mortem, 
I found an injury of the left ureter about an inch and a half above 
its lower end. Its walls were so broken down that they could not 
be separated from the surrounding tissue. The ureter was occluded 
at the point of injury. There was a circumscribed exudation in the 
cellular tissue around the injured part. Suppuration had begun at 
the site of injury, showing that the starting-point of the inflamma- 
tion was a traumatism of the ureter. Above the occluded portion 
the ureter was dilated, and filled with pus and urine. There was 
acute nephritis on that side, together with inflammation of the ureter 
on the right side, and some infiltration of the cellular tissue around 
it. The right kidney was also inflamed, or at least markedly hyper- 
aemic. Circumscribed cystitis of a mild character existed. There 
was not enough in the clinical history, nor in the lesions found, to 
indicate a grave form of septicaemia. The cause of death was, no 
doubt, uraemia. 



CHAPTER LIL 

ECTOPIC GESTATION. 

The subject of ectopic gestation is one of such importance as to 
have induced me to add a chapter upon it to this edition of my 
work. Much, if not all, that has been done of late years to advance 
our knowledge of the matter has come from the gynaecologists, and 
the management of these cases has naturally fallen into the hands of 
those who are skilled in abdominal and pelvic surgery. 

The term ectopic gestation is applied to the imj)lantation and 
development of the impregnated ovum outside of the cavity of the 
uterus. In the past, authors have held that there was a great variety 
of these peculiar gestations, which were classified according to the 
location of the ovum. Tubal, ovarian, abdominal, and interstitial, 
were all said to occur frequently. Further investigation has led to 
the conclusion that tubal gestation is either the only primary form, 
or at least that any other origin than in the tube is rare. That 
ovarian pregnancy may exist, is shown by the cases of Bandl and 
Nouratoif. 

In the interstitial form the ovum grows in that part of the tube 
occupying the wall of the uterus, and as the ovum enlarges the 
uterine wall sjijlits and develops to accommodate it. I feel satis- 
fied that many so-called cases of ectopic gestation are really gestation 
in one horn of an imperfectly developed uterus. The abdominal 
variety was supposed to arise from an impregnated ovum which had 
become firm in the peritoneal cavity and developed there. Recent 
observations show that such cases are primarily tubal gestation, that 
rupture of the tube occurs, and that the ovum escapes and forms an 
attachment to the peritonaeum. 

A statement which would express the modern views is about as 
follows : All cases are at first tubal. Rupture of* the tube takes place 
in all cases, as a rule, and the ovum escapes either into the peritoneal 
cavity, or in between the folds of the broad ligament. After escape 



ECTOPIC GESTATION. 921 

of the ovum in one or the other direction, the ovum may live and 
develop into either the intraperitoneal or extraperitoneal variety. 
In the extraperitoneal variety a second rupture may take place, and 
thus it may become intraperitoneal, or the ovum may develop to 
maturity in the broad ligament. 

Pathology. — There is at all times some abnormal condition of the 
sexual organs which renders extra-uterine gestation possible. This 
will be referred to w^hen treating of causation. 

The natural tendency in tubal gestation is for rupture to take 
place with escape of the ovum. Eupture occurs before the four- 
teenth week in ninety per cent of the cases. Previous to the com- 
plete rupture there are occasionally minor lacerations of the peritoneal 
covering of the tube. Especially is this likely to take place when 
there has been peritonitis which has impaired the nutrition and elas- 
ticity of this serous membrane. There are usually slight hgemor- 
rhages either into the tube or into the peritoneal cavity, attended 
with pain in the earlier lacerations. When rupture occurs, death 
ensues in most cases, unless relief is afforded by operating. Death 
is caused by haemorrhage and shock in the majority, but some sur- 
vive this, and iinally succumb to peritonitis or septicaemia from sup- 
puration. 

In case of rupture the ovum may plug the opening, and arrest 
the haemorrhage ; the placenta may form attachment to the perito- 
naeum, and the gestation go on to full term as an abnormal preg- 
nancy. This is, perhaps, one way in which an abdominal pregnancy 
may occur, but it is rare. 

Finally, the ovum may die in the tube and become encysted, or 
disappear by absorption. 

Causation. — There is really very little known about the etiology 
of ectopic gestation Several theories have been advanced with 
much positiveness, but there are few facts to sustain them. It is 
known that the ovule usually becomes impregnated in the Fallopian 
tube, but why it should attach itself to the mucous membrane of the 
tube and develop there is not clearly made out. Johnston states, 
in the Transactions of the American Gynaecological Society for 1S90, 
that the mucous membrane of the tube and the peritonaeum, w^hen 
divested of their epithelium, are capable of forming a nidus in which 
an ovum may develop, and disease of the tube causes such exfolia- 
tion of the epithelium. The old theory is, that some narrowing of 
the tube which would obstruct the passage of the ovum to the uterus, 
at the same time that all other conditions were favorable, would lead 
to such result. In later times it is supposed that, owing to some 
60 



922 DISEASES OF WOMEN". 

disease of tlie endometrium, the impregnated ovum is retarded in its 
transit or entrance to the uterus, and, finding favorable conditions in 
the tube, remains to develop there. Another explanation of the 
retention of the ovum in the tube is, that there are oftentimes 
small diverticula in the lower side of the tube into which the ovum 
may fall and be retained. After all, it is evident that but little is 
known definitely on this subject that can be positively stated. 

Symptomatology. — It is of the highest importance that a diagno- 
sis should be made in ectopic gestation as early as an opportunity 
is afforded to do so. No matter what the treatment may be, the 
medical attendant has great advantages if he knows the nature of the 
case before being called upon to interfere by operative or other 
means. On this account the symptomatology has a special interest 
which I desire to direct attention to, especially so because in the 
past few years much has been said about the difficulty or impossibility 
of making a diagnosis. An experience neither more nor less than 
that wliich usually falls to the lot of one in twenty years' practice, 
has led me to believe that the diagnosis of ectopic gestation is just 
as possible as of normal gestation. There are exceptional cases, I 
know quite well ; but the rule is, that one can be as sure of the pres- 
ence of an ectopic gestation as of any of the various forms of in- 
ternal disease. 

The Signs and Symptoms of Tubal Pregnancy. — These may be pref- 
aced by the statement that a considerable period of sterility -usually 
precedes the history of such a case. On examination we shall find 
many of the following conditions : 

1. The signs of pregnancy are present. Menstruation ceases, or 
is replaced by the peculiar haemorrhages mentioned below. Nausea 
and vomiting, salivation, and changed appetite are noted. We find 
some of the early mammary signs, such as increase in size and firm- 
ness of the gland, erectility of the nipple, glandular follicles, pig- 
mentation, oedema and elevation of the primary areola, and enlarged 
veins. Pelvic discomfort is marked. Compared with normal preg- 
nancy, the signs are often more pronounced. In most of the cases 
I have seen, the patients have been irritable and apprehensive. 

2. Haemorrhages from the uterus occur usually in gushes of 
larger or smaller amount, and they are especially liable to appear at 
the time of the painful paroxysms. The haemorrhages and the cast 
often suggest miscarriage. 

3. A decidual cast is thrown off, and this cast has no foetal vil- 
losities. It may be entire, or may be discharged piecemeal. Shreds 
must be looked for. 



ECTOPIC GESTATIOK 023 

4. The patient suffers from paroxysms of pain wliicli are " abrupt, 
violent, supervening on apparent liealth, cramp-like in character, 
and usually referred to the seat of the fruit-sac, while the more acute 
paroxysms are attended with collapse and signs of internal haemor- 
rhage." 

On bimanual examination the uterus is found (1) to be enlarged ; 

(2) it is displaced according to tlie size and situation of the fruit-sac ; 

(3) the cervix is open ; and (4) the uterine cavity is empty. When 
metrorrhagia exists or the decidua has been expelled, there need be no 
hesitation in using the sound. The tumor which is detected beside 
the uterus or behind it is a cyst, (1) tense, (2) tender, (3) pulsating, 
and (4) rapidly growing. This tumor is extremely sensitive. There 
is evidence of extraordinary vascularity in the pulsating vessels which 
are easily felt, and this is a sign seldom found except in intraligament- 
ous fibroma and occasionally in cancer. The rapidity of growth is 
striking as it is watched from week to week, and frequent examina- 
tions are therefore required. 'No other cyst likely to be confounded 
with it increases with the same rapidity. In the absence of adhesions, 
ballottement of the whole tumor is said to be feasible, but I believe 
it to be difficult. Contractions of the tube, in imitation of the uterus, 
have been detected as the time of rupture approached. 

The tumor must be differentiated from hydrosalpinx or pyosal- 
pinx, small ovarian cyst and pregnancy in one horn of a double 
uterus, but the only conditions that I have seen which are difficult 
to distinguish from tubal gestation are pregnancy in a uterus bicornu 
and haematocele. The presence of the other horn of the uterus, and 
the fact that the pregnant horn is continuous from the cervix up- 
ward, and the tumor denser than a distended tube, are sufficient. 
This I feel sure of^ having made a differentiation in several cases. 
A small pelvic hgematocele, if seen soon after the haemorrhage, can 
not be distinguished from the tumor of ectopic gestation, except by 
the diff'erence in history. The presence of the products of peritoni- 
tis which preceded the gestation, and also a uterine fibroma, as com- 
plications, may make a positive diagnosis impossible. 

Symjptoms developed when Rujptttre takes place. — When the rupt- 
ure opens into the peritoneal cavity, the symptoms are extremely 
grave. The pain is agonizing ; the surface of the body becomes cold 
and is bathed in clammy perspiration ; the pulse is feeble and rapid ; 
the temperature becomes sub-normal, and there is nausea, while dis- 
tention of the bowels from flatus soon comes on. In short, there 
is shock, and it gradually becomes more profound as the haemor- 
rhage continues. If relief is not afforded, the patient dies from 



924 DISEASES OF WOMEK 

shock. In case the bleeding ceases and the patient rallies, the symp- 
toms of shock gradually give way to evidences of peritonitis ; and if 
this does not prove fatal, septicsemia may supervene, or, more rarely, 
recovery may follow. 

When the rupture opens into the broad hgament, pain and symp- 
toms of depression are present, bnt the shock is not marked. The 
symptoms are like those of subperitoneal hsematocele, and are not 
violent in all cases. 

Physical Signs present when RuptuTe has taken place. — The 
signs at this stage are of value in determining the direction of the 
rupture. In the intraperitoneal variety, the sac of Douglas becoming 
filled with blood, the soft, fluctuating haematocele can be felt through 
the vagina. This, taken in connection with the violent symptoms, 
confirms the diagnosis, and enables the surgeon to operate with more 
certainty of avoiding the extraperitoneal variety. In the subperi- 
toneal variety the tumor is lower in the pelvis and is solid to the 
touch from the first, and in this way can be made out with sufiicient 
certainty to enable one to forego operation for the time being, which 
is the wise course to pursue. 

Treatment. — The management of ectopic gestation involves many 
questions. The course to be pursued must depend upon the stage 
of the gestation and the character or form of each case in hand. 

In cases which come under observation before rupture has taken 
place, the life of the embryo should be arrested. This principle of 
treatment has for a long time been advised, and several methods of 
accomplishing this object have been advocated. Electricity, accord- 
ing to the latest reports, is the safest and surest of all forms of treat- 
ment, and, notwithstanding much opposition from certain quarters, 
I feel bound to advocate it. 

Some prefer the interrupted, others the continuous current. The 
way of applying it is to place a cotton-covered ball electrode in the 
vagina at the place nearest to the tumor, and a large flat sponge or 
clay electrode over the abdomen on the side where the tumor is. 
The strength of the current should be gradually raised until it is as 
strong as the patient can bear, and continued from five to eight 
minutes. This should be repeated daily until the life of the embryo 
ceases, which is sho^vn by the tumor becoming smaller. To any 
one who has treated uterine fibromata with electricity this treat- 
ment of ectopic gestation is easy. The manipulations are about the 
same. 

When the gestation is arrested in this way the ovum is disposed 
of by absorption. The tissues are soft, being very largely composed 



ECTOPIC GESTATION. 925 

of water, and are as readily taken up as blood-clots. That the 
ovum may die from natural causes and be disposed of without detri- 
ment to the patient, is admitted, and the same results can and do 
follow when electricity is employed to secure the initial stage in the 
process. 

Owing to the opposition which has been raised to this mode of 
treatment, it seems necessary that a word or two -should be said in 
its favor, and also to notice the reasons given for the objections that 
have been made. 

That this method is efficient, I believe upon the ground that 
many operators have tried it and found it successful. I also have 
seen cases so cured. The most powerful argument for it is that of 
Brothers, who collected fifty-three cases treated by electricity, as re- 
ported in the American Journal of Obstetrics for April, 1890. By 
the simple, safe, and certain method 1 recommend, all the foetuses 
were killed and not one of the mothers was lost. It is gross unfairness 
to attribute the deaths in this table to electricity. The fatal result 
in the patients of Braxton-Hicks, Duncan, and Boulton was due to 
the other measures employed. In the first case it was due to the 
puncture of the cyst through the vagina -Q.Ye weeks later, which 
started an internal haemorrhage. With Janvrin's patient internal 
haemorrhage had begun, and the case was not a proper one for elec- 
tricity. Tait lost two out of thirty-five patients treated by laparot- 
omy, and Yeit three in twenty. In the hands of less expert men 
abdominal section is still more dangerous. Electrical foeticide comes 
nearest to the spontaneous method of relief. If carefully and skill- 
fully employed, it is safe ; should it fail, or if any unfavorable re- 
sults follow, such as suppuration in the tube, or rupture, the case 
can still be treated by abdominal section. 

The objections have little weight. The first is, that we have no 
moral right to sacrifice the life of a foetus under any circumstances. 
If this objection came from a certain class of theologians, it should 
be accepted as a guide in dealing with those who desire to accept 
that doctrine. Strange to say, it comes from those who urge and 
advocate abdominal section and removal of the ovum. The argu- 
ment a^ppears to be that it is wrong to arrest ectopic gestation with 
electricity, but right to do so by abdominal section. It has been 
said that the embryo may be destroyed by electricity, but the pla- 
centa will continue to live and grow, and prove dangerous. The 
one or two reported instances are very doubtful. Brothers's collec- 
tion contains no such case. At the time when electrical treatment 
is indicated, the placenta is only partially developed, and it loses its 



926 DISEASES OF WOMEJST. 

yitality when the death of the foetus occurs. That is the rule in nor- 
mal gestation, and there is no proof that the natural law is reversed 
in tubal gestation. There is said to be danger of the dead ovum 
causing suppuration and septicsemia. That is true, but it seldom 
does so ; and, as stated already, if a case goes wrong, abdominal sec- 
tion can be employed with as good results, or better than after rupt- 
ure takes place. 

Finally, the most unfair argument of all is, that those cases 
claimed to be cured by electricity are cases of mistaken diagnosis. 
This is not worthy of serious consideration. 

Treatment after Primary Ruptiire of the Sac. — Abdominal section 
is the method of management which is called for in case rupture 
has taken place. "When symptoms of rupture appear, the operation 
should be at once resorted to. If it is possible to determine that 
the rupture is into the broad ligament, operation is not called for ; 
but in case there is doubt, the abdomen should be opened, and if 
there is no hgemorrhage into the peritoneal cavity, the abdomen 
should be closed. When the peritonseum is reached, the presence 
of blood within it is shown by the dark color of the translucent 
membrane and by its bulging, and, if further evidence is required, 
by nicking the peritonaeum and passing in a pipette toward the cul- 
de-sao. The operation is the same as in removal of the diseased 
tubes. Search for the tube should be made, and, when found, it 
should be withdrawn and its attachments ligated and the whole 
removed. This controls the bleeding, and then the peritoneal cavity 
can be cleansed of blood. The wound is closed in the usual way. 
This operation is indicated and is highly successful, when the ovum 
has died and decomposition has followed. 

Years ago I saw a patient who was not treated in any way until 
acute inflammatory symptoms had developed. She was then treated 
for peritonitis, and died of septicaemia. Post-mortem, the gestation 
sac was easily separated from the peritoneal adhesion and removed. 
This experience enabled me to save tlie life of a similar patient by 
abdominal section. 

When the rupture of the tube opens into the broad ligament the 
foetus should be killed by electricity, if such rupture has occurred 
before the end of the third month, and the mass is small enough to 
permit of absorption. Later, the case should be left to develop as 
an abdominal gestation. This is the most rational treatment, as I 
understand it. Should the ovum die in the extraperitoneal variety, 
it may be in part absorbed, and the remainder become encysted and 
prove harmless ; but it may decompose, and cause great disturbance. 



ECTOPIC GESTATION. 927 

Under such circumstances it is better to operate than to wait for the 
sac-contents to be discharged through the pelvic viscera. The ques- 
tion then arises, whether abdominal section or eljtrotomy should be 
resorted to. In case the sac is low in the pelvis and can be reached 
easily through the vagina, I should prefer to follow the practice of 
T. G. Thomas. The following is his description : " The safest and 
best method of dealing with the case would be to introduce a large 
Sims's speculum, and, bringing the dull cautery of Paquelin's appa- 
ratus to a red-heat, cut slowly into the sac. The foetus, but not the 
placenta, should be removed, a linen bag iilled with cotton used as a 
compress fixed externally upon the abdomen over the site of the 
tumor with adhesive plaster, and the sac carefully filled with antisep- 
tic cotton, which should be renewed every thirty-six hours." 

Operation after Rupture of the Sac. — When secondary rupture 
occurs, with dangerous hsemorrhage, laparotomy is indicated, just 
as it is in primary rupture. 

In this condition the time to operate and the method of proced- 
ure are determined for the surgeon, to a great extent at least. The 
secondary rupture is indicated by the local and constitutional symp- 
toms, which in some cases are comparatively mild, while in others 
they are marked and call for interference. 

On opening the abdomen^ the foetus, which has escaped into the 
abdominal cavity, is removed, and the cavity cleared of blood. The 
rent in the sac is sought for and all hsemorrhage arrested. If the 
rent is in front, the walls of the sac are fastened to the parietal 
wound with sutures and the sac drained. When it happens that the 
rupture is so situated that it can not be brought to the wound in the 
abdominal wall, it should be closed, and another opening, large 
enough to admit a drainage-tube and the cord, made in front. The 
further treatment should be as if the original rupture had occurred 
in front. Drainage of the abdominal cavity should also be em- 
ployed. 

Operation when the Foetus is Dead. — In this condition it should be 
understood that while the foetus has died the sac is not ruptured, 
and that the decomposition of the foetus causes danger from septic 
infection, and the danger therefrom demands operative interference. 

The complications which may occur in this state are very vari- 
able. The length of time that is permitted to elapse, and the extent 
of inflammatory products or changes that may take place, give char- 
acteristics that render no two cases alike. Some cases are as simple 
to operate on as an ordinary abdominal abscess ; in others, intestinal 
and other adhesions are found that make the operation the most 



928 DISEASES OF WOMEiT. 

difficult. The method of procedure must depend upon the nature 
of the case, and the judgment and dexterity of the surgeon must be 
the only guides. 

The whole gestation sac may be removed as easily and in the 
same way that an ovarian cyst is removed, the conditions being 
favorable. When the adhesions are such that it can not be safely 
removed, as determined by a careful exploration, then the sac should 
be aspirated and its walls fixed to the abdominal wall and drained. 
Drainage of the abdominal cavity as well as of the sac may be neces- 
sary. As a rule, the placenta should be removed. 

Operation at or before Full Term when the Child is Alive. — It is no 
easy matter to decide whether to operate at once and save the child 
— primary laparotomy — or to wait until spurious labor has come on, 
the child has died, and sepsis threatens — secondary laparotomy. If 
we wait until the child has been dead two or three months, the pla- 
cental vessels atrophy, and the danger of hsemorrliage from the pla- 
cental site after the operation is vastly diminished. Harris gives 
thirty per cent as the death-rate in secondary laparotomy. Hereto- 
fore the maternal mortality has been so great after primary lapa- 
rotomy (ninety-six per cent previous to 1880) that it was not justifia- 
ble, but since the death-rate dropped to sixty per cent between 1880 
and 1888 (Harris), and as it has dwindled to twenty-eight per cent 
since 1888 (Pozzi), th-e operation demands consideration. The sac 
is stitched to the abdominal wound and then incised. The child is 
removed and the cord tied. Then the placental site may be con- 
trolled by a haemostatic suture, and the placenta, together with a large 
part of the sac, may be removed. If this procedure is not feasible, 
the placenta may be left to come away later, and the cavity carefully 
drained. 

The after-treatment consists in pumping out the fluid that ac- 
cumulates in the sac and does not escape through the tube. If the 
drainage is not perfect in this wise, the cavity should be washed out 
through the tube. This is generally necessary in order to remove 
the debris of the placenta as disintegration goes on. Portions of the 
placenta are liable to slough, and it is then necessary to enlarge the 
wound to permit such masses to escape. 

There are certain complications which may occur. Several of 
the most common I here refer to, and discuss their management. If 
there is much fluid in the sac, it should be removed by tapping. In- 
testinal adhesions in front should be separated in the usual way, if 
that is possible. If not, the portion of the sac which is adherent 
should be divided around the point of contact, and allowed to remain 



ECTOPIC GESTATION. 929 

attached to the intestine, using the opening thus made to extract the 
child. 

When the attacliment of the placenta is in front and in the line 
of incision, its presence there is indicated by the extraordinary vas- 
cularity and dark color of the sac-wall. This may possibly enable 
the surgeon to avoid making the opening at that point of the sac. 
If the placenta can not be avoided, the incision should be quickly 
made and the bleeding arrested with forceps, until sutures can be 
introduced through placenta and sac-wall to control the bleeding. 
Every effort should be made to avoid the placenta, as it complicates 
the operation greatly. 

In the subperitoneal variety the sac consists of the peritonaeum 
and broad ligament tissue, and differs in vascularity, thickness, and 
character from the intraperitoneal variety. The sac looks like an 
intraligamentous ovarian cystoma or uterine myoma. In this con- 
dition of things there is much hemorrhage where the sac is opened, 
and the same manipulations are called for that were described in 
speaking of opening the sac at the point of placental attachment. 



CHAPTEK LIII. 

GYNECOLOGY AS RELATED TO mSANITY IN WOMEN. 

The relations whicli exist between the sexual organs of women 
and diseases of the brain and nervous system, had occupied some of 
my time and attention in the past, but my opportunities for observa- 
tion were limited, until Dr. J. C. Shaw^, the Medical Director of the 
King's County Insane Asylum at Flatbush, invited me to take charge 
of the gynecological practice in that institution, counting among its 
inmates about four hundred female patients. This gave me extended 
facilities for studying this special department of medicine as it pre- 
sents itself among the insane. 

Upon entering this field of observation, I was confronted with 
an entirely new phase of practice, in which the ordinary methods of 
investigation were of little value. ]^o correct histories could be 
obtained from the patients themselves, and the records kept by the 
physicians in charge, though full and correct in all that pertained to 
the mental conditions, afforded but little information of value to the 
gynecologist. 

The routine business common to all these institutions, made it im- 
perative to acquire the art of investigation in this department. In- 
formation was sought in records, regarding gynecological practice 
among the insane, without avail, and so I was obliged to devise a 
method of examining patients. 

The system of investigation adopted, and the phenomena ob- 
served, together with the deductions drawn therefrom, form the 
subject matter of this chapter. 

It should be clearly understood that the subject to be discussed 
is limited simply to the relation which gynecology bears to insanity. 

Regarding the etiological relations of diseases of the brain and 
sexual organs, little need be said at this date. I take it for granted 
that an will agree that insanity is often caused by diseases of the 
procreative organs, and on the other hand, that mental derangement 



GYNECOLOGY AS RELATED TO INSANITY IN WOMEN. 931 

frequently disturbs the functions of other organs of the body, and 
modi ties diseased action in them. Either may be primary and caus- 
ative, or secondary and resultant. In the literature of the past, we 
find the gynecologist pushing his claims so far as to lead a junior in 
medicine to believe that if the sexual organs of women were pre- 
served in health, insanity would seldom occur among them. While 
the psychologist, or alienist, holds that women will lose their reason 
and regain it, without much help or hinderance from their repro- 
ductive organs. The ablest and best men on both sides take the 
human organization as a whole, and give to each portion its legiti- 
mate share of credit for good and evil. On this branch of medicine 
the boundary-lines which divide the gynecologist and psychologist 
often touch and cross each other, and it is necessary that we should 
know where they touch, and where they diverge. To know this 
will insure a cordial agreement as to w^hen the two specialists shall 
act separately, and the conditions which require them to labor to- 
gether for the benefit of those who suffer in body and mind. 

From my investigations, I have been led to the belief that up to 
the present time the effect of disease of the sexual organs in women, 
in causing and keeping up insanity, has been more correctly studied 
than the influence which insanity exercises upon the sexual organs. 
This opinion may have been formed from the fact that my observa- 
tions have been made especially from the standpoint of the gyne- 
cologist, and therefore the other side of the question has not been so 
clearly seen. But the reasons for holding this belief are, that the 
one line of investigation is easier than the other, and our literature 
shows that most investigators have chosen the sexual organs as the 
starting-point of their inquiries. The gynecologist has the advan- 
tage of knowing when his patients have uterine or ovarian disease, 
and if insanity follows in any of his cases, he may be able to estimate 
the influence of the primary disease in causing the mental disorder. 
On the other hand, the psychologist may have a number of insane 
patients who suffer from uterine and ovarian diseases which may 
escape his notice. This may readily occur even among the cases or 
insanity caused by diseases of the sexual organs. Derangement of the 
mind often obscures all the symptoms of bodily disease, and therefore 
the medical attendant is liable to be misled. One is not apt to over- 
look insanity in patients known to have disease of the sexual organs, 
and hence the advantage that the gynecologist has in studying the 
relations of these two forms of morbid action. For reasons such as 
these, one should not find fault with psychologists for not having 
done more to develop this branch of medical science, but rather re- 



932 DISEASES OF WOMEK 

mind gynecologists tliat they have done so little, considering their 
opportunities. 

At this point, attention may be directed to the way in which 
diseases of the sexual organs cause insanity. We have long recog- 
nized the cause and the effect, but the mode of action of the one in 
producing the other may be admitted, in many cases at least, as an 
open question. 

The rule has been to attribute insanity (when developed during 
the existence of uterine or ovarian disease) to reflex action. The 
well-known book by Dr. IT. R. Storer affords a notable example of 
the position given to reflex action in the etiology of insanity. This, 
no doubt, is an important factor in the cause of mental derangement, 
but it is far from covering the whole ground. An acute disease of 
the ovary or uterus, or a displacement of either, is sufficient to 
cause a mental derangement (in some highly sensitive organizations) 
which will subside when the disease of the pelvic organ is relieved, 
Such cases are no doubt reflex in character, but there are a great 
many more cases of insanity that can be traced to the sexual organs 
in which reflex action takes no part. Take, for example, cases of 
uterine disease, preceding by an interval of years the mental de- 
I'angement which follows without any increase of the primary disease. 
In such cases it is probable that impaired nutrition of the brain, 
which occurs as the result of prolonged suffering, is the direct cause 
of insanity, and not the result of reflex action from the disease of 
the sexual organs. The irritation and exhaustion produced by uter- 
ine or ovarian disease is simply the predisposing indirect cause of 
the insanity, while the direct cause is some lesion of nutrition of the 
brain itself. 

One of the most marked and important causes of insanity 
among women of the poorer class is frequent child-bearing and 
lactation. The extraordinary taxation imposed by their maternal 
duties deranges the mind of a vast number of women. This fact 
is quite familiar to medical men, and has been proved to my own 
satisfaction by clinical observation, and a perusal of the records of 
all the asylums in this country. From these reports I find that 
the largest number of insane women is found at from twenty-five 
to forty years of age, and that of these a large percentage have 
been married and have had children. Of this number, some may 
have had disease of the sexual organs, but there can be no doubt that 
a large number become insane from the exhaustion of frequent child- 
bearing and lactation, without any other complications. These cases 
of insanity can be traced indirectly to extraordinary functional activ- 



GYNAECOLOGY AS RELxVTED TO INSANITY IN WOMEN. 933 

ity of the sexual organs, but can not be called cases of reflex insani- 
tj. There is a difficulty in turning the records of asylums to account 
because they are not kept so as to bring out the history of the sexual 
organs, or the relation of their diseases to insanity. J^evertheless, 
there are facts sufficient to show that child-bearing and lactation bear 
an important relation to mental disorders. 

There is too little in our literature on the subject of mania 
caused by the exhaustion of the nervous system from child-bearing 
and nursing. The true bearing of the sexual organs in this connec- 
tion is liable to escape notice, because the mental weakness or nerv- 
ous exhaustion is the first manifestation of disease. There is no 
uterine or ovarian disease to attract the physician's attention while 
he is seeking for the cause of mania. Our books tell us of anaemia 
from prolonged lactation, but say little of the nervous exhaustion 
which may or may not be accompanied by anaemia. 

Every practitioner has observed the conditions of mental depres- 
sion and nervous irritation and debility which occur during the 
child-bearing period of women's life. We may go beyond the 
apparent effects of rapid and long-continued reproduction and ask 
the question. Why should the exercise of this normal function so 
often sacrifice the mental and physical health of woman? The 
answer is, that too many other duties are usually imposed upon 
women during the age of reproduction. Among the poor the wife 
is required to work for her livelihood, as well as to give life and 
sustenance to her children ; even among the rich we often find 
that very little allowance is made for maternal duties. These com- 
bined exertions of reproduction and every-day labor to which so 
many women are subjected, are more than the strongest constitution 
can endure. This will be granted by the most fanatical believer in 
the mental and physical capabilities of women. It may be ques- 
tioned if even physicians at all times fully appreciate the demand 
made upon the female organization by reproduction. During preg- 
nancy, there is often an apparent or real increase in the nutrition of 
the individual, which gives the highest evidence of good health ; 
there is also a manifest ability to do ordinary work that is sui-prising. 
But if this power is abused, as it often is, the result must be general 
debility. The resistance to this overtaxation may be and often is 
maintained for a long time. The first pregnancy and lactation do 
not necessarily break down the constitution, but the repetition of 
these, with the duties and cares which multiply as life advances, 
exhaust the nerve power, and lead in many cases to mental derange- 
ment. This is especially so among those who have been raised in 



934 DISEASES OE WOMEN. 

ease and comfort without acquiring habits of industry. When 
daughters of these families marry into less affluent circumstances, or 
when Fortune turns against the young wife and mother, and disap- 
pointment and privation are added to the taxation of household 
duties and the raising of a family, then we have all the conditions 
necessary to cause insanity. Many cases having such a history can 
be found in our asylums. The insanity occurring under such cir- 
cumstances is generally centric and not reflex, and yet dependent to 
some extent on the sexual organs. 

Many authorities might be quoted to prove that the normal func- 
tional activity of the reproductive organs sometimes tends to under- 
mine the brain and nervous system to an extent sufficient to lead to 
insanity, and I am satisfied, from cases occurring in my own prac- 
tice, that it occasionally does so. 

There is a prevailing opinion that insanity occurs very frequently 
at puberty, and the cause in such cases is generally ascribed to reflex 
action. This, no doubt, is frequently the true cause, but not always. 
Mental and emotional excitement occurring in connection with de- 
mands of the reproductive system abruptly made at that time, 
may develop insanity at puberty, when the sexual organs are well 
developed and perform the function of menstruation normally. 
Again, insanity occurring at the menopause, in place of being due 
to disease of the sexual organs, can often be traced to deranged con- 
ditions of the general system, such as imperfect elimination, or as the 
older authors state, the sudden suppression of an accustomed discharge. 

There are other causes of insanity, such as the puerperal state 
and venereal excesses, which are fully discussed in our books and 
need not be mentioned here. Enough has been said to show that 
a clear distinction should be made in the study of etiology, between 
insanity caused by existing active disease of the sexual organs, and 
insanity arising from brain exhaustion produced by prolonged or 
excessive functional activity of these organs while free from any 
disease. We incline to the belief that as ras.ny or even more cases 
of insanity can be traced to the latter, i. e., exhausting activity, as to 
the former, i. e., active disease of the sexual organs. The bearing 
of these facts upon the diagnosis and treatment of insane women 
will be apparent to all medical men. In the one class of cases the 
sexual organs require no attention, except as factors in the indirect 
cause of the mental affection ; while in the other the disease of the 
sexual organs is the direct cause of insanity, and tends to keep it up 
until removed by the treatment which ought in all cases to be insti- 
tuted. 



GYNECOLOGY AS RELATED TO INSANITY IN WOMEN. 935 

Having briefly referred to some of the influences of the sexual 
organs in causing insanity, the next question which I propose to 
discuss is the effect of insanity upon the function of the reproduc- 
tive system. Observations were made on two hundred women rang- 
ing in age from seventeen to forty-six years, the period of active 
functional life of the sexual organs. These observations were contin- 
ued during six months, and at the end of that time eight were lost, 
some by death, and the others discharged from the asylum. Of the 
remaining 192, there were only 27 who menstruated regularly and 
normally ; 30 did not menstruate at all ; 4 menstruated once ; 8 
twice; 10 three times; 18 four times; 34 five times; 24 six times 
at irregular intervals ; 31 seven times, and 6 eight times during the 
six months. This record shows to what a marked extent the men- 
strual function is disturbed among insane women. There are per- 
haps other conditions in which two hundred women possessing the 
same degree of physical health could be found with menstrual 
derangements to the same extent. These disorders of menstruation 
are accounted for in two ways. The impaired general nutrition 
which prevails so extensively among the insane is sufficient to arrest 
the menses in a large proportion of cases. The general health is 
reduced so far below the normal standard, as to compel the indi- 
vidual to suspend all functional activity not absolutely necessary to 
life. The same symptoms occur in any of the exhausting diseases, 
such as phthisis pulmonalis, as every physician well knows. The 
amenorrhoea is conservative when it occurs under such circum- 
stances, and should not be considered abnormal, but as a fortunate 
provision of Nature to relieve an overtaxed organization from a duty 
which can be neglected with less injury to the individual than any 
other function. That the suspension of menstruation is caused by 
malnutrition, is evident from the fact that the same condition 
occurs in other diseases when the nutrition is markedly impaired. 
Additional proof is also obtained from the fact that the sexual 
organs in such cases are generally found to be anaemic, presenting 
the appearance of those who have passed the menopause, except 
that there is not always atrophy such as we find in the very aged. 
A sufficient number of the cases having suppression of the menses 
that are recorded in the table were carefully investigated to show 
that there was, in most of them, impaired nutrition of the sexual 
organs, to account for the amenorrhoea. On the other hand, amen- 
orrhoea finds its cause in the diseased nervous system alone. A few 
cases, and especially one, came under observation in which the gen- 
eral nutrition was normal, the pelvic organs were in a healthy con- 



936 DISEASES OE WOME:Nr. 

dition, and still there was amenorrhoea due, beyond doubt, to imper- 
fect innervation. An abundance of proof could be brought forward 
to show that the deranged innervation, such as occurs among the 
insane, causes suspension of the function of the sexual organs ; but 
it will suffice to recall the fact that mental shocks, prolonged mental 
anxiety, and the like have been long recognized as causes of acute 
suppression of the menses. Cases without number are on record 
which establish this fact. 

As a number of patients who came under my care menstruated 
regularly and some of them had menorrhagia, or too frequent men- 
struation, the question arises. Why was that the case, all of the pa- 
tients being insane ? According to the rule forced upon us, that in- 
sanity tends to suspend the menstrual function, all the insane should 
have amenorrhoea, but they do not. The answer then is, that men- 
struation is affected in proportion to the degree of insanity. In 
those patients who menstruated normally the insanity was of a mild 
type, not sufficient to impair either the nutrition or the innervation 
of the pelvic organs to any marked extent ; and in those who suf- 
fered from menorrhagia, or too frequent menstruation, there was 
some form of uterine disease present. 

The deductions drawn from the phenomena observed may be 
formulated as foUow^s : Well-developed insanity, with impaired gen- 
eral nutrition, causes suppression of the functions of the sexual or- 
gans. Deranged innervation tends to produce the same result. In 
mild forms of insanity menstruation may continue normal. Excess- 
ive menstruation among the insane is usually caused by uterine dis- 
ease, and should be accepted as evidence of such. 

The opinion just stated is based upon clinical observations of the 
menstrual function, which may be taken to a great extent at least as 
an index of the condition of the organs concerned. It can not, how- 
ever, be claimed that amenorrhoea is a sure indication that all the 
functions of the sexual organs are suspended. We know well that 
ovulation may continue, while menstruation is absent, and so may 
the venereal desire ; but such cases are exceptional. Moreover, 
there are other reasons for beheving that a general functional inac- 
tivity prevails in those cases characterized by amenorrhoea. In a 
few cases of this class, when a post-mortem examination has been 
made, the evidences of ovulation have been absent. More facts are 
needed to fully establish this point ; still enough have been obtained 
to show that ovulation is arrested in some cases of insanity. Again, 
maternal and marital affections (ruling passions in women) are, as a 
rule, rarely manifested by this class of insane women. This would 



GYNECOLOGY AS RELATED TO INSANITY IN WOMEN. 937 

also tend to prove that the sexual organs return for the time to a 
condition of functional inaction resembling that of childhood or ad- 
vanced age. 

Trusting that sufficient evidence has been produced regarding 
the iniluence of insanity upon the function of the sexual organs, the 
question which follows in succession is, What effect does insanity 
exert upon their diseases ? 

We shall first take up the functional diseases of the uterus, and, 
according to the necessities arising from the character of our nomen- 
clature, we must include under this head all those affections in which 
the function of the organ is deranged because of an impaired inner- 
vation and blood circulation. 

It appears that all authorities upon uterine pathology agree that, 
in a host of cases of uterine diseases met in practice, there exists an 
excess of nerve irritability and hyperaemia, without any well-defined 
change in the structure of the tissues excepting that which occurs in 
all pathological congestions — a condition which implies a change in 
the quantity of blood and caliber of the vessels, which is not perma- 
nent, but disappear under infiuences which enable the vessels to re- 
gain their original size and tonicity. This class of diseases is dis- 
tinct from the organic, in which well-defined and easily recognized 
changes of structure exist. For want of a more comprehensive and 
accurate name these are called functional affections. 

The influence of insanity on this class of diseases is most favor- 
able. It may be stated fairly that such diseases disappear upon the 
occurrence of mental alienation. To use a popular but unscientific 
expression, insanity tends to cure functional diseases of the uterus. 
This statement may excite question and opposition, but chnical ob- 
servation compels this conclusion and renders it worthy of the high- 
est consideration. It should be clearly borne in mind that the influ- 
ence of insanity does not extend beyond this class of diseases, that it 
does not affect organic diseases to the same extent at least. This is 
not claimed by any means ; but the effect upon the functional forms 
of disease is marked, and, we think, unquestionable. There are ex- 
ceptional cases no doubt, but the rule holds good. The subjects of 
masturbation and those who labor under a mental derangement of a 
venereal kind, while free from uterine and ovarian disease, have cen 
trie affections only, and belong to a class to be referred to at another 
time. 

Attention was first directed to this subject by watching the pro- 
gressive history of a case which was under observation for conges- 
tion of the uterus and leucorrhoea. She became insane, and her 
61 



938 DISEASES OF WOMEN. 

nterine disease disappeared without local treatment. The disease of 
the uteras, added to other causes of mental disturbance, was sup- 
posed to have acted a part in the causation of her insanity. Other 
cases followed this one, until sufficient mateiial was obtained to show 
the relationship of the mental and uterine disease. Some cases, in- 
deed quite a few, whose history of former uterine diseases I obtained 
through friends, when examined in the asylum were found to have 
recovered. The disappearance of functional uterine disease upon 
the occurrence of insanity agrees with the facts observed regarding 
the influence of mental alienation on the function of the sexual or- 
gans. That the vital activity of an organ or system can be lowered 
by the influence of disease existing elsewhere in the organization to 
an extent sufficient to cause arrest of function is evidence that func- 
tional disease may disappear under the same circumstances. The 
same action is observed in the pathology of other diseases. The lit- 
erature of medicine furnishes numerous illustrations of the fact that 
disease in one portion of the body may disappear upon the develop- 
ment of morbid action in another. This is all comprehended under 
the head of the antagonism of diseases, the same law which recog- 
nizes the physiological antagonism of medicines. It is not claimed 
that all functional disease of the uterus disappears when insanity is 
developed ; but this occurs so generally that those cases in which the 
uterine derangements persist may be classed as exceptional. 

This peculiarity of uterine disease among the insane has prob- 
ably led psychologists to attach but little importance to uterine 
disease as complicating mental affections. This is the only reason 
or excuse for those who claim that the sexual organs require but 
little notice from those who have the care of insane patients. Such 
observers have caught a fraction of the truth, and endeavor to make 
it cover more ground than belongs to it. The influence of insanity 
in arresting the progress of uterine disease relates almost exclusively 
to the class of affections above stated, and does not apply to other 
forms of local disease of an organic character. Those who claim 
much more are as far from the right as the gynecologist, who be- 
lieves that the great majority of women who lose their reason do so 
because of disease of the sexual organs, and that all insane women 
should be placed in charge of the specialist for diseases of women. 

The class of insane women who have simply functional diseases 
of the sexual organs requires no care from the gynecologist, beyond 
what is necessary to establish the fact that there exists no organic 
disease. This in itself is an important service, and one which only 
the gynecologist can render ; but when the diagnosis is settled in 



GYNAECOLOGY AS RELATED TO INSANITY IN WOMEN. 939 

the negative, tlie patient should be left to the psychologist. The 
relief of deranged menstruation and functional diseases must come 
through improvement of the general health and the cure of the 
insanity, and not bj any local treatment, except hygienic, and this 
the alienist is as competent to afford as the gynecologist. 

The same rule of practice should be followed in the management 
of this class of patients that is observed in cases in which the func- 
tion of the sexual organs is deranged from any other disease of the 
general system, like pulmonary phthisis, nervous exhaustion, and 
such like ; i. e., to restore the general system to health, and trust 
that restoration of the sexual organs will follow. 

There is one class of insane patients, already referred to, in 
which there appears to be a functional derangement of the sexual 
organs, which would apparently call for the gynecologist's care ; 
viz., those who manifest insane sexual desire, or whose ravings are 
obscene and licentious. Such cases often take their origin in some 
disease or abuse of the sexual organs, w^hich either disappears or 
eludes the diagnostic skill of the gynecologist. 

While the mental derangement points to trouble of the pelvic 
organs, no disease can be detected. Local treatment in such cases 
can effect no benefit, because the disease is centric and not reflex ; 
hence the treatment must be directed to the nervous system. When 
it is stated that manifestations of sexual excitement may originate in 
the brain or nervous system, we have clearly in mind that the same 
symptoms may arise from disease of the pelvic organs, and will 
refer to that class of cases at another time. We take the ground 
that abnormal sexual excitement sometimes has its origin in the 
nerve centers, and that too when the sexual organs are free from 
disease, and that a mental derangem.ent of an emotional character 
may continue after the disease which caused it has subsided. The 
importance of clearly distinguishing diseases of the sexual organs 
that cause and tend to keep up insanity, and mental derangements, 
which exist independent of lesions of ether organs, can hardly be 
overestimated. 

Organic diseases of the sexual organs exercise a most important 
influence in causing insanity, and tend to retard recovery from it. 
Under that head are included all the appreciable diseases of the 
ovaries, uterus, and vagina, that are characterized by change of 
structure or position. These need not be named individually, but I 
may mention some conditions that are more properly called results 
or products of disease, in contradistinction to active morbid pro- 
cesses. Such are the products of pelvic peritonitis and cellulitis, 



940 DISEASES OF WOMEN". 

cicatrices of the cervix and vagina. These, by adhesion and con- 
tractions, often cause severe pelvic pains, sufficient to induce or 
keep up insanity. 

These affections of the sexual organs frequently cause insanity 
directly or indirectly, and unlike functional diseases, are not as a 
rule relieved by the mental derangement which follows. It is evi- 
dent that no disease of the brain or nervous system could favorably 
influence a displacement of the uterus or the ovaries, nor modify the 
ill-effects of a laceration of the cervix, nor check a leucorrhoea due 
to that lesion of the organ. On the contrary, insanity which too 
often debars the sufferer from requisite treatment, and even the 
care that she would take to favor her infirmities while in sound 
mental health, tends to prolong if not to aggravate the pelvic 
disease. These diseases of the sexual organs remain as a disturbing 
element to keep up the derangement of the brain, or at least to 
retard recovery. ' In this way the insanity and the disease of the 
sexual organs act in concert to maintain each other to the detriment 
of the unfortunate sufferers. There are but few cases in this class, 
where the disease of the pelvic organs can be lessened in severity by 
the presence of insanity. The general anaesthesia which occurs in 
some forms of insanity may relieve the patient from the suffering 
of pelvic pain arising from old adhesions. So also a dysmenorrhoea. 
which is largely due to an exalted nerve irritability, may be modi- 
fied or entirely relieved. In prolapsus of the ovaries and chronic 
ovaritis, the pain may be calmed by the mental derangement as by 
opium, but still in such cases, although the patient appears to suffer 
less, the question may be asked : Does not the disease exert as pow- 
erful an energy for evil upon the brain and nervous system of the 
sufferer? It is possible that while the patient is so fully engaged 
with insane fancies as to disregard physical pain, the local irritation 
exists none the less, exercising its depressing influence. Be this as 
it may, it is certain that whenever disease exists in the sexual organs 
of insane women, the condition of the brain, if influenced thereby 
at all, must be affected unfavorably. If such diseases of the sexual 
organs are capable of causing insanity, (a fact that appears to be 
settled by our best thinkers on both sides) they must also tend to 
keep it up. It is to this class of genital affections among the insane, 
that the science and art of gynecology apply with most marked 
advantage. Functional derangements and diseases of the sexual 
organs among the insane may be left alone, and the patients com- 
mitted to the psychologist, with confidence that they will secure all 
the benefits that medical science can afford. In this department 



GYKECOLOGY AS RELATED TO IN"SANITY IN WOMEN". 941 

those who care for the insane may insist npon non-interference from 
us. But when insane women have organic diseases, they have a 
right to all the relief that they can obtain from gynecology, and 
that is certainly very much. 

Another question follows at this point ; What are the ascertained 
effects upon the insane of curative treatment of the co-existing 
diseases of the sexual organs ? 

Any one who is familiar with our current literature would, on 
first thought, be prompted to say that the results are very gratifying, 
— even wonderful. There are cases recorded without number in 
which all varieties of strange nervous affections and mental dis- 
orders have disappeared as if by magic, upon the replacement of a 
dislocated uterus, or the restoration of a lacerated cervix. Much of 
this literature may be worthy of acceptance as exact science, but 
there is much of it that may be challenged as having no other claims 
upon our notice than the fact that recovery of one affection followed 
the cure of an accompanying one ; but what relation the one had to 
the other remains a mystery. To accept all such testimony as cor- 
rect, would be as unsafe as to believe that sense and reason could be 
promptly restored to all insane women by curing any disease of the 
sexual organs that they had. 

A careful consideration of this subject has led to the conclusion 
that acute affections of the brain and nervous system, that are wholly 
due originally to disease of the sexual organs, will be relieved, in a 
large majority of cases, by curing the primary affection. The effects 
of treatment of the disease of the sexual organs will be in proportion 
to the duration and severity of the mental derangement. In sub- 
acute mania, caused or aggravated by disease of the sexual organs, 
marked benefi.t or prompt recovery may be expected to follow the 
cure of the pelvic disease. On the other hand, chronic mania asso- 
ciated with disease of the sexual organs, will often remain unchanged 
after the local disease has been relieved. That is sometimes the case 
when the patient's general health improves by the local treatment. 

This follows the rule that is observed in other departments of 
pathology, in which two or more diseases are related to each other 
in the order of cause and effect. A secondary disease does not 
always disappear when the primary one, which acted as the cause of 
the other, is cured. This defines the limits of the success which the 
gynecologist may expect to have in practice among the insane. 

Having endeavored to outline the conditions which demand 
the service of the gynecologist among the insane, attention is now 
invited to the subject of diagnosticating diseases among this class of 



942 DISEASES OF WOMEI^. 

patients. The rules laid down in our text-books on diseases of 
women for investigating pathological conditions apply to practice 
among the insane only in part. 

There is an endless number of difficulties which are not en- 
countered among sane women. To overcome these and find means 
and ways of ascertaining the clinical history and physical indications 
of the state of the sexual organs, has occupied much of my study, 
and the results I now offer. 

The first thing required is the natural and clinical history of the 
sexual system. Very few insane patients can give an account of 
themselves in this respect ; even those who comprehend questions 
and are disposed to answer them, are often opposed to discussing 
their uterine conditions, and when they can be induced to talk on 
the subject, the physician is left in doubt as to the correctness or 
value of their testimony. We are obliged, therefore, to depend upon 
the methods employed in the investigation of diseases in children, 
and seek information from those who have had the care of the 
patients. Parents, friends, and nurses can generally give us the facts 
that we require to know. By diligent inquiry in this way, the lead- 
ing points in the history of the patient up to the development of in- 
sanity can be usually learned, and if the attention of the nurse or 
guardian is directed to a careful observation of the function of the 
sexual organs, much valuable knowledge can be obtained. Atten- 
tion is especially directed to this part of the clinical history of 
insane patients, because it is sadly neglected by the great majority of 
those who have the care of them. In looking over the records kept 
in the asylums one can see how little information they afford regard- 
ing the state of the organs of reproduction. The age of patient, and 
whether married or single, and the number of children, if any, that 
she has had, is, in many institutions, all that bears upon gynecology. 

For example, in the tables of nearly all the asylums for insane 
people in this country, we find that those showing the age at which 
insanity first appeared, give the number of those under ten, from 
ten to fifteen, from fifteen to twenty, and so on ; or else they are 
arranged under twenty, and from twenty to thirty, thirty to forty, 
etc. This shows how impossible it is for any one to obtain from 
such tables the information which the gynecologist needs, on the 
relations of puberty and the menopause to insanity. These records 
may give the information required by the psychologist, but are of 
little value for our purpose. To know the condition of the sexual 
organs, we require all available information regarding their func- 
tional manifestations. In order to accomplish this, I arranged a 



GYNECOLOGY AS RELATED TO INSANITY IN WOMEN. 943 

case-book for use in onr county asylum, which was approved by the 
medical director. Dr. Shaw. The headings in the blank pages are 
so arranged as to call out the history bearing upon the condition of 
the sexual system, etc. Here is the history of a case as it reads from 
this form of record : 

Date. 

Name, A 3f Age, 30. Nativity, Oermany. 

Temperament, Sanguine, Nervous. Diathesis, None. 

i Mental, Good. 
Development, ■< Inherited Disease, None. 

( Physical, Fair. 
Social condition. Married eleven years. No. of Children, 1. 

Age of first, 10. Age of last, 8-|- ms. 

Miscarriages, Period of Gestation, Date of first. Date of last, 



Menses, j Before insanity. 

First at 16, ( After insanity. 



Character. Eecurrence. Duration. Amount. 

Normal. Every 28 days. b to Q days. Normal. 
Absent. 

Effect of Menses on Nervous System before insanity. No effect observed. 
Effect of Menses on Nervous System after insanity. Not observed. 
History of Disease of Sexual Organs before insanity. Normal until after her fifth childy 

when she had slight prolapsus of the uterus and bladder. 
Mental manifestations and Symptoms of Disease of the Sexual Organs. Complained of 
weakness, lohUe nursing her last three children. She walks in a stooping position ; 
has leucorrhoea, and states that there is something in her womb which ought to come 
away. 
Physical signs of Disease of Sexual Organs, Uterine cavity three and three fourths inches 
long. Slight eversion of cervix ; anieversion of the uterus ; prolapsus of the urethra and 
bladder. 

Diagnosis, Imperfect involution and anteversion of the uterus. Eversion of the cervix 
from slight laceration ; prolapsus of the bladder and urethra. 
Form of Insanitv, Melancholia. 



( of Insanity, Five months. 
Duration -s of disease of Sexual Organs, Began at the birth of her third child, and increased 
[ at her last confinement eight and a half months ago. 

iof Insanity, Exhaustion from reproduction and overwork. 
of disease of Sexual Organs, Debility, and resuming her evcry-day labor too 
soon after confinement. 

A part of this history, you observe, was obtained from the mother 
of the patient, who also furnished some valuable facts regarding her- 
self ; the rest is added by the medical attendant. 

Such a record supplies the required information for the use of 
the gynecologist, and, although it may not be the best attainable, 
we venture to state that it is better for the purpose than the records 
usually kept in such institutions, and it is, therefore, commended 
to those in charge of insane women who desire to avail themselves 
of the aid of those skilled in the treatment of the diseases of women 



94^ DISEASES OF WOMEN. 

The design of this method of making clinical histories is to ascer- 
tain, as far as possible, the condition of the sexual organs before 
insanity occurred, and the relation of the mental derangement to the 
functions of reproduction. Then follows the history of the function 
of these organs as shown by the condition of the menstrual function. 
Lastly, the observance of such mental manifestations as may indicate 
the existence of disease of the sexnal organs. Under this head much 
valuable information may be obtained by carefully studying the pa- 
tient's speech and behavior. This portion of the subject may be 
brought out more clearly by a few details. 

Dr. Shaw called my attention to one girl who walked about the 
ward in a stooping position, and held her hands upon the genitals as 
if trying to support them. She made no complaint, nor was she 
sane enough to answer questions about herself, but her actions raised 
the suspicion that there was something w^rong, and, upon examina- 
tion, she was found to have uterine disease. Another case, a mar- 
ried woman, and the mother of children, was able to converse quite 
rationally on many subjects, but was greatly disturbed by imagining 
that men ^dsited her at night for unlawful purposes. She also had 
disease of the uterus. There are a great many ways in which cere- 
bration indicates that the brain is influenced by the sexual organs, 
and such derangement of thought, shown by abnormal conversations, 
is often valuable in pointing to disease of the pelvic organs. Ob- 
scene or licentious mental expressions do not always indicate disease 
of the sexual organs. The demoralization of the insane may come 
from previous bad habits and associations, or may be developed by 
the disease of the nerve centers while the sexual organs are normal. 
Perverted thought, when cut off from the control of the reason, may 
be made manifest while there is no physical signs of disease outside 
of the brain itself, but when deranged emotions manifested by ob- 
scene speech and actions are observed in those previously modest and 
chaste, they should be taken as probable evidence of disease of the 
sexual organs, and should lead to further investigation. 

Physical exploration of the pelvic organs of insane women has 
heretofore been beset with many difficulties. Indeed, it has been 
impossible to examine some insane patients. Persuasion is often 
useless, and forcible efforts to control them ends mostly in defeating 
the examiner, or injuring the patient, or both. The only practical 
way has been to anaesthetize by ether, and this has proved to be very 
unsatisfactory. It is often a laborious task to give ether or chloro- 
form to a maniac, to say nothing of the danger and injurious after 
effects. With such past experience, we need not wonder that the 



GYNECOLOGY AS RELATED TO INSANITY IN WOMEN. 945 

practice of gynecology has found but little favor among those hav- 
ing the care of iusane women. One has only to witness the distress- 
ing scene enacted in forcibly giving ether to a maniac, for the pur- 
pose of treating a uterine disease, to be satisfied that the results do 
not justify the means. 

To overcome all these difficulties, I use the nitrous-oxide gas as 
an anaesthetic, and I am happy to say that it answers the purpose 
admirably. It acts quickly and pleasantly, and has none of the chok- 
ing effect which is so distressing to those of sound mind, and pecul- 
iarly horrifying to the insane. 

The mode of administering it is with the apparatus used by the 
dental surgeons, to whom we are greatly indebted for these valuable 
appliances. In place of using the mouth-piece, a rubber cap is era - 
ployed, which fits over the patient's mouth and nose. The more 
manageable cases are placed upon the table while the gas is admin- 
istered. Refractory ones are placed in a chair, with a back high 
enough for the head to rest against. An attendant on each side 
holds the arms ; the operator places the cap over the face, and holds 
it, while a third assistant holds the head steady between his hands 
and the back of the chair. A few inspirations are usually sufficient 
to quiet the most unruly patient ; then the inhaling proceeds quietly 
until anaesthesia is complete. 

By opening the valves so as to admit a portion of air, the effect 
can often be kept up without producing the arrest of blood aeration, 
which occurs in profound anaesthesia from this agent. It is well, if 
possible, to avoid this extreme anaesthesia, and the lividity which 
follows, because it changes the appearance of the tissues, and might 
thereby interfere with minute examination, especially if the exam- 
iner is unaccustomed to it. 

So far as the observations of Dr. Shaw and Dr. Arnold of the 
asylum have extended, no unpleasant effects have followed the use 
of this agent ; on the contrary, many of the patients who took it ap- 
peared to be improved in their mental condition. One young girl, 
who had been many months in the asylum, and who spent most of 
her time in mental and physical inaction, asked for work to do, and 
became quite useful after having taking the gas a few times. The 
improvement could not have come from the treatment of her local 
derangement, because she did not improve in that respect. There 
is much reason for believing that the nitrous-oxide gas is a valuable 
tonic in cases of extreme debility of the nervous systeui. Drs. 
Barker and Blake related some instructive cases bearing upon this 
subject in the New York Obstetrical Society. Both these gentlemen 



946 DISEASES OF WOMEN. 

employed the gas in such small doses as not to cause angesthesia, and 
the effect was very satisfactory. I believe that further observation 
will show that like good will follow in some cases where it is given 
as an angesthetic. If that should prove to be so on further observa- 
tion, this agent will exercise a double advantage. As it is, the use 
of it in the treatment of diseases of the sexual organs of insane 
women, is a contribution from gynecology to the management of 
the insane which promises to be of great benefit. 

The physical signs of disease vary but little from those in ordi- 
nary cases, with a few exceptions which may be mentioned. The 
absence of tenderness is almost always marked. Patients rarely 
complain of being hurt by examination or treatment. This is so 
marked as to be noticeable in those who permit treatment without 
taking an anaesthetic. When the mental derangement has existed 
for several months or longer, and the menses have been absent, the 
vagina and cervix uteri are found to be pale and anaemic. The 
appearance resembles that found in those who have passed the 
menopause. This does not indicate any active disease, but simply 
shows the inactive condition of the circulation and nutrition. Con- 
stipation is so common among insane women as to make it almost 
the rule to find the rectum distended. This fact should be borne 
in mind so that the bowels may be emptied before making an ex- 
amination, thereby disposing of one of the chief obstacles to our 
investigations. The diagnosis of ovarian diseases — obscure at all 
times — is most difficult among the insane. It is well known how 
much dependence is placed upon the presence of tenderness on 
pressure in ascertaining the condition of the ovaries. This valuable 
sign is lost when we examine under an angesthetic, and even when 
the patient is conscious, we can not always tell by her behavior 
whether pressure hurts or not. Still in one case I was able to 
detect disease of the right ovary by observing that the organ was 
enlarged, prolapsed, and tender on strong pressure. There was also 
rigidity of the abdominal muscles on that side, which was marked 
w^hen compared with the left side. 

Regarding the diseases which occur among the insane there is 
little that is peculiar or worthy of notice. We find the same organic 
affections of the uterus and ovaries as are met among rational beings, 
and while their symptoms are modified by the state of the nervous 
system, their physical signs are the same. It is possible that malig- 
nant disease of the uterus occurs more frequently among the insane. 
There are reasons for believing also that the products of former 
diseases, such as puerperal metritis, pelvic peritonitis, and cellulitis, 



GYNECOLOGY AS RELATED TO INSANITY IN WOMEN. 947 

are found more frequently in this class of patients than among sane 
women. 

The treatment of diseases of the reproductive organs of insane 
women is based upon the general principles which guide the physi- 
cian in ordinary practice. There are, however, circumstances peculiar 
to this class of patients which must, of necessity, modify our treat- 
ment, and therefore I will mention some facts of clinical observa- 
tion which are worthy of notice. While discussing functional dis- 
ease, such as amenorrhoea, it was claimed that constitutional treat- 
ment alone was required in such cases. That is doubtless true. 
Local treatment can accomplish very little to relieve such conditions, 
either among the insane or the sane. Persistent amenorrhoea seldom 
yields to local treatment, such as stem galvanic pessaries, the local 
use of electricity, leeching and blistering the uterus, and the diffi- 
culties in the way of employing such means among the insane, 
practically exclude their use. 

In the management of cervical endometritis it is necessary to use 
means that do not require frequent repetition. On that account the 
hot-water douche (a most valuable remedy) can not be used, because 
these patients will not permit the nurse to treat them, nor will they 
use it themselves, except in rare cases. There is the same objection 
to the use of the cotton and-glycerine tampon, which requires to be 
renewed every day. In such cases I have used with advantage an 
application of equal parts of tinct. iodine and carbolic acid once a 
week. This is a sedative, and also changes the abnormal action of 
the mucous membrane, causing a diminution of the leucorrhoeal 
discharge, the erosion of the surface disappearing, not by being 
replaced by cicatricial tissue, but by the restoration of normal epi- 
thelium. "When improvement begins it is well to lessen the pro- 
portional quantity of the acid. 

Vaginitis is also a difficult disease to treat among insane women, 
owing to the same objections to the vaginal douche. Little progress 
can be made in the management of this affection without thorough 
cleanliness, and that is difficult to obtain in insane patients. In 
fact vaginitis and vulvitis occur oftener in this class of patients 
than in those of sound mind, owing apparently to want of care 
in keeping the parts clean. Some of the most marked cases of 
purulent vaginitis that have ever come under my observation were 
among my patients in the asylum. 

The treatment adopted in these cases consisted in iirst cleansing 
the mucous membrane thoroughly with a sponge, and then applying 
a mild solution of nitrate of silver, or sulphate of zinc with tluid ext. 



948 DISEASES OF WOMEN". 

of hydrastis Canadensis and water, and then introdncing a tampon of 
marine lint. This tampon is changed for a new one every two or 
three days, nntil the inflammation subsides. The tampon is sufficient 
to cure most cases of vaginitis without any other treatment. It sepa- 
rates the inflamed surfaces, and by absorbing the secretions, keeps 
the parts perfectly clean. The tar which it contains is one of the 
most useful remedies in inflammations of mucous membranes, and 
besides fulfills a modern demand in surgery in being antiseptic. 
This method of treating vaginitis has been tried in general practice 
and answers well, but it is among the insane where its value is most 
marked. 

Endometritis polyposa, or fungosa, with the monorrhagia which 
is caused thereby, is quite a common affection among the insane, 
judging from the number of cases which have come under my own 
observation. To meet the indications and the circumstances which 
the accompanying insanity gives rise to, I have adopted with satis- 
factory results, the following method of treatment : 

Having made a positive diagnosis, a small curette or scoop hav- 
ing a flexible stem, is carried into the cavity of the uterus, and the 
whole of the fungous material broken down and removed. This 
simple operation is often followed by complete recovery. Some- 
times the polypoid growth returns and a repetition of the operation 
is necessary. In a very few cases it has returned again and again, 
but has finally yielded to the use of bichloride of mercury given in 
the usual doses, and the application of tinct. iodine and carbolic 
acid after the use of the curette. There is nothing new in this 
method of treating the disease in question, except in omitting dila- 
tation of the cervix by tents as a preliminary. This is entirely 
unnecessary and should be avoided, because it is painful and dan- 
gerous, while the use of the blunt scoop is less likely to give after- 
trouble than any other form of intra-uterine treatment that I am 
familiar with. The methods of treating this affection given in our 
books are first to dilate, use the curette, and finally use some caus- 
tic or alterative application to the whole endometrium. This re- 
quires that the patient should be confined to bed several days, care 
being taken to prevent the development of inflammation ; and with 
all there is danger. Such practice is impossible among the insane. 
There are few of that class of patients that can be kept quiet in bed 
while undergoing such treatment. The same object can be attained 
without interrupting the patient in her usual mode of life. I have 
used the curette in office-practice with as little caution as I make 
mild applications to the cervical canal, and have so far had no acci- 



GT>TECOLOGY AS EELATED TO INSANITY IN WOMEN. 949 

dents. In the confidence based upon that experience the treatment 
was employed among the insane, and the results have been quite 
satisfactory. 

With regard to lacerations of the cervix uteri in the insane, I 
have simply to say that the evil that such lacerations give rise to are 
well enough known to warrant us in declaring that any patient with 
that complaint, whether sane or insane, has a right to claim relief at 
the hands of the gynecologist. The success of the operation de- 
pends to some extent upon the details of after treatment, such as 
rest in bed and cleanliness. This is difficult to obtain among insane 
women, but in lieu of that I have employed a method of operating 
which gives fair results, even when the patient goes around during 
the healing process, to wit : the use of silk sutures and the lint tam- 
pon in place of the douche. 

The advantage is that the sutures can not wound the vagina like 
the ends of a silver- wire suture, and the tampon supports the uterus 
and guards against putting a strain upon the sutures when tlie 
patient moves or sits up. This method is well adapted to practice 
among the insane: While I would hesitate to operate in the usual 
way upon an insane patient, I have practiced the method described 
with marked success. A question m,ay be raised as to the propriety 
of leaving a silk sature in the cervix during the time requisite for 
healing. The constant heat and moisture to which the suture is ex- 
posed, certainly favor decomposition of the silk, and if that should 
occur the suture would cause suppuration. I have demonstrated 
that no such results need be feared when the silk is properly pre- 
pared by immersing it for several hours in a composition of melted 
wax, salicylic and carbolic acids. I have removed such a suture 
from the cervix that had been there for one year, two months and 
twenty days. The patient was operated upon, and when removing 
the sutures after union had taken place, I carelessly missed one. 
She soon became pregnant, and six weeks after confinement, she 
called for examination to ascertain the effect of delivery on the cer- 
vix, and then I found the missing suture. It had caused no great 
trouble, and was in a very good state of preservation. 

. The pelvic pain or neuralgia, which arises from cicatrices of the 
cervix and vagina, is often very annoying, and calls for treatment. 
Marked relief follows after dividing the bands of cicatricial tissue. 
In two insane cases I have now in mind this treatment was the only 
means that could easily be employed, and the results were very satis- 
factory. One was a case of scar tissue of the cervix from the reck- 
less use of nitrate of silver ; the other had a number of cicatricial 



950 DISEASES OF WOMEN. 

bands in the vagina resulting from gangrenous vaginitis occurring 
after scarlatina in girlhood. 

Displacement of the uterus, i. e, prolapsus and versions can be 
treated with good results, excepting when there are anatomical or 
functional imperfectioDS of the perinseum. The displaced uterus 
can be readily restored and a pessary adjusted while the patient is 
angesthethized. It is necessary to frequently examine such patients 
while wearing pessaries, because they may suffer without complain- 
ing. 

The most important difficulty is encountered in the management 
of displacements in those having an imperfect perinaeum. Pessaries 
or supports held in place by being fastened to the body can not be 
used, and on that account we are limited to intra-vaginal pessaries, 
which require the presence of the perinseum. To restore a lacerated 
peringeum would be easy, but to secure the after treatment neces- 
sary to a good result is often difficult. Investigation of this subject 
among the insane has been very limited, but I am satisfied that in 
many cases the restlessness of such patients would render the use of 
the silver wire unsatisfactory. I believe that the use of silk would 
be a great improvement in these plastic operations among the insane. 
Attention is called to this subject as a field inviting experimenta- 
tion. Flexion of the uterus, in its various forms, gives rise to much 
suffering when the menstrual function continues, and dysmenorrhoea 
is a common result. In quite a number of patients with flexion 
there is amenorrhoea, and in such flexion alone is presumed to give 
no trouble. There is no reason for believing that a flexion unasso- 
ciated with any other disease of the uterus would give rise to dis- 
turbance of the brain or nervous system in a patient who does not 
menstruate ; so I have avoided local treatment, believing that noth- 
ing would be gained by anything that could be done. But when the 
menses recur, and are painful, the probabilities are that the flexion 
is the cause of the dysmenorrhoea, and it should be relieved if possi- 
ble. Knowing how difficult flexions are to cure, when the circum- 
stances are favorable, it need hardly be stated that the treatment of 
such deformities in the insane is often very unsatisfactory. The 
most daring gynecologist would hesitate to use a stem pessary, or 
perform division of the cervix, in a patient who could not be well 
controlled during the after treatment. In flexion of the cervix divi- 
sion might be practiced in patients not too violent and uncontroll- 
able. As a rule, however, the treatment in such cases is limited to 
subduing any excessive irritability of the uterus, and securing a suffi- 
cient size of the canal by dilatation or incision, if necessary, and in 



GYNECOLOGY AS EELATED TO INSANITY IN WOMEN. 951 

cases of forward flexion of the body, much might be gained by 
straightening the uterns and keeping it so, as far as possible by 
means of Thomas's anteflexion pessary, or some similar instrument. 

There are forms of dysmenorrhoea (not dependent upon flexion 
of the uterus or any known mechanical cause) that are presumed 
to arise from ovarian disease, or some abnormal condition of the 
nerves supplying the sexual organs. In these cases the local signs 
are negative, and the only true evidence of the painful menstrua- 
tion is the fact that the insanity is aggravated at that time, and the 
patient may indicate by the position of the body, and by placing the 
hands over the lower portion of the abdomen, that the seat of sufi!er- 
ing is in the pelvis. For cases of this kind I know of no special 
local treatment that is beneflcial. Fortunately this form of dys- 
menorrhoea is rare among the insane. The reason for this is that 
the tender and irritable uterus and ovaries are relieved, in some 
cases at least, upon the appearance of insanity. 



ITSTDEX. 



Acute endometritis, 111. 

ovaritis, 457. 
Adeno carcinoma, 401. 
Affections resembling ovarian neoplasms, 

499. 
After treatment of fistula, 901. 
Albert Smith pessary, BlY. 
Alexander's operation, 331. 
Allantois, 82 
Amenorrhoea, 52. 
Ampere, 369. 

Amputation of cervix uteri, 413. 
Anaesthesia in diagnosis, 19. 
Anaesthetics, mode of administration, 19,249. 
Anatomical relations of bladder and urethra, 

618. 
Anatomy of bladder, 609. 

cervix, 610. 

coats, 610. 

corpus, 610. 

form, 610. 

fundus, 610. 

glands, 611. 

inter-ureteric ligament, 612. 

ligaments, 619. 

nervous supply, 613. 

openings, 612, 

ostium, urethral, 612. 

position, 610. 

relations to urethra, 618. 

sphincter, vesical, 611. 

trigone, 610. 

ureters, 612. 

vascular supply, 61-3. 
of Fallopian tubes, 547. 

coats, 547. 

length, 547. 

orifices, 547. 
62 



Anatomy of Fallopian tubes, relation to 
uterus and broad ligaments, 547. 
of ovary, 438. 

blood-supply, 439. 

length, 439. 

minute anatomy, 443. 

ovulation, 446. 

relation to broad ligament, 439. 

thickness, 439. 

weight, 439. 

width, 439. 
of pudendum, 77. 

clitoris, 77. 

glands, 77. 

labia majora and minora, 76. 

hymen, 76. 

vestibule, 77. 
of urethra, 613. 

coats, 614. 

diameter, 613. 

length, 613. 

meatus urinarius, 616. 

relation to bladder, 618. 

Skene's glands, 614. 

sphincter, urethral, 617. 
of uterus, 171. 

arbor- vitEe, 174. 

body, 171. 

cavity, 172. 

cervix, 171. 

fundus, 171. 

length, 171. 

mucous membrane of cavity, 172. 

mucous membrane of cervical canal, 
174. 

Nabothian glands, 174. 

OS externum, 172. 

OS internum, 172. 



954 



DISEASES OF WOMEN". 



Anatomy of uterus, peritoneal covering, 172. ' 
utricular glands, 1*73. 
walls, 1Y2. 
width, 171. 
of vagina, 99. 
coats, 100. 
connection with cervix uteri and pelvic 

floor, 99. 
length of walls, 99. 
orificium, 80. 
Anteflexion of tl^ uterus, 57. 
acquired, 57. 
causation, 61. 
congenital, 57. 
illustrative cases, 69. 
of body, 58. 
of cervix, 57. 
of cervix and body, 58. 
pathology, 58. 
physical signs, 60. 
symptomatology, 59. 
treatment, 64. 

Elliott's adjuster, 68. 
pessaries, 68. 
Hewitt's, 68. 
Thomas's, 68. 
surgical methods, 64. 
Anterior-labial hernia, 91. 
Antero-posterior laceration of cervix uteri, 

243. 
Anteversion, 286. 

pessaries, Thomas's, 68. 
Antiseptic dressings, 136. 
Anus, atresia of, 82. 
Apostoli's electrodes, 375. 
Arbor- vitEe uterina, 174. 
Areolar hyperplasia of uterus, 220. 
Arrest of haemorrhage, 527. 
Art of investigation, 1. 
Atlee, W. L., M. D., 313. 
Atresia of anus, 82. 
of bladder, 816. 
of vagina, 101. 
of vulva, 82. 
Atrophy of muscles of pelvic floor, 160. 
of muscular tissue of vaginal walls from 

abuse of pessaries, 335. 
of uterine walls, 332. 

from senile malnutrition, 124. 

Baker's operation for amputation of cervix 
uteri, 414. 



Benign growths, 804. 

mucous polypus, 804. 

myxoma, 804. 

papilloma, 406. 

polypoid hypertrophy, 804. 
Bilateral laceration of cervix uteri, 245, 347. 

complicated, 253. 

incomplete, 256. 

uncomplicated, 252. 

with thickening of everted lips, 244. 

with unequal division of cervix, 244. 
Bimanual method of examination, 9. 
Bladder, anatomy of, 609. 
development of, 609. 
diseases, 653. 
distended, 498. 

dislocation of, 760; hernia of, 769. 
Bleeding disease of uterus, 356. 
Broad ligament, 282. 
Bulbi vestibuli, 78, 80. 
Byrne's battery, 372. 

Calculus, 780. 
Cancer, 398. 
juice, 399. 
of cervix, 398. 
of body of uterus, 417. 

causation, 418. 

causing \Tilvitis, 84. 

diagnosis, 418. 

pathology, 417. 

physical signs, 418. 

prognosis, 418. 

symptomatology, 418. 

treatment, 418. 
Carcinoma, 111, 473. 
Carunculae myrtiformes, 81. 
Catheter, use of, 137. 

Cauliflower excrescence of cervix uteri, 401. 
Caustics in treatment of cancer of uterus, 

411. 
Cautery clamp, 513. 

Paquelin's, 111. 
Cervical canal of uterus, 173. 
Cervical endometritis, 179. 

exanthematous, 176. 

gonorrhoeal, 176. 

in an imparous woman, 196. 

in an imperfectly developed uterus, 197. 

puerperal, 176. 

with hyperplasia of mucous membrane, 
191. 



INDEX. 



955 



Cervical endometritis with stenosis and cys- 
tic degeneration, 192. 
Cervix uteri, hypertrophic elongation of, 124. 
hypertrophy of, 343. 
laceration of, from parturition, 242. 
operation for restoration of, 249. 
Chlorosis, 44. 

Chronic corporeal endometritis, 212, 
cystitis, 716. 
endometritis, 178. 
Chronic inversion of uterus, 273. 

mistaken for fibrous polypus, 269. 
ovaritis, 4o4. 
Cicatrices of cervix uteri and vagina, 259. 
causation, 259. 
complications, 262. 
illustrative cases, 262. 
symptomatology, 259. 
treatment, 261. 
Clamp, hgemorrhoid, 151. 
Classification of neoplasms of ovary, 473. 
Clitoris, 76, 82. 
Cloaca, 82. 
Coccyodynia, 167. 
causation, 168. 
illustrative case, 169. 
pathology, 167. 
physical signs, 168. 
prognosis, 168 
symptomatology, 167. 
treatment, 168. 
Nott's, 168. 
Simpson's, 168. 
Coccyx, removal of, 170. 
Colloid cancer, 400. 
Complex cystoma of ovary, 476. 
Compound cyst of ovary, 474. 
Concave mirror, 18. 
Condyloma, 406. 
Constriction at external os uteri, 68. 

at internal os, 68. 
Contents of ovarian cysts, 480. 
Corporeal endometritis, 202. 
Corpus clitoridis, 77. 

Courty's method of restoring inverted ute- 
rus, 274. 
Crescentic laceration of cervix uteri, 247. 
Croupous cystitis, 756. 
Cup pessary causing vulvitis and ulceration, 

339. 
Curette, 21, 198, 362. 



Curetting, method of, 209. 
Curved scissors, Emmet's, 138. 
Cusco's speculum, 14. 
Cylindrical-celled epithelioma, 401. 
Cystic degeneration of cervix uteri, 181. 
Cystitis, 703, 710. 

acute, 711. 

causation, 730. 

chronic, 716. 

croupous, 756. 

diagnosis, 758. 

diphtheritic, 710. 

epi-cystitis, 710. 

gonorrhoeal, 710. 

pathology, 716. 

prognosis, 758. 

symptomatology, 720. 

treatment, 737, 759. 
Cysto-carcinoma, 473. 
Cysto-fibroma, 477. 
Cysto-sarcoma, 473. 
Cysts of vagina, 109. 

Dawson's battery, 372. 
Depressor, Hunter's, 14. 
Dermoid cysts, 477. 
Development of bladder, 620. 

of Fallopian tubes, 22. 

of Graafian follicles, 445. 

of ovaries, 442. 

of sexual organs, 22. 

of urethra, 620. 

of urinary oi'gans, 22. 

of uterus — primary, 22. 
secondary, 24. 

of vagina, 22. 
Dilatation of cervix uteri, 69. 

of urethra, 9, 849. 
Dilators : 

urethral, 17. 

uterine, 17. 

Goodell's, 17. 

Hanks's, 17. 
Diseases of Fallopian tubes, 359, 547. 

of ovaries, 454. 

of pudendum, 84. 

of urethral glands, 879. 

O-T urethra, 818. 

of urinary organs, 609. 

of uterus, 171. 

of vagina, 99. 



956 



DISEASES OF WOMEN". 



Dislocation of urethra, 861. 
Displacements of ovaries, 466. 

of uterus, 286. 
Double vagina, 100. 
Dragging of pedicle in ovarian tumor, 

485, 
Drainage in ovarian tumor, 526. 
Dressings, 136. 
Ducts, Miiller's, 22. 
Dudley's method of treating fistula in auo, 

165. 
Dupuytren's operation for atresia, 103. 
Dysmenorrhoea : inflammatory, 204. 

membranous, 229. 

neurotic, 59. 

obstructive, 59. 

ovarian, 456. 

Ecraseur, 862, 413. 
Ectopic gestation, 920. 
Electrolysis : ampere, Z&9, 
anions, 3'71. 
battery, 371. 

Byrne's, 372. 

chloride of silvei", 372. 

Dawson's, 372. 

Law, 372. 

Leclanche, 372. 

Piffard's, 372. 
cations, 371. 
circuit, 367. 
conductors, 368. 
current, 367. 
electrodes, 368. 
electrolytic, 371. 
electro-motive force, 368. 
electro-negative elements, 371. 
electro-positive elements, 371. 
faradism, 367. 
galvanism, 367. 

in the treatment of fibroids, 394. 
law of currents, 369. 
negative elements, 367. 
negative pole, 367. 
non-conductors, 368. 
ohm, 369. 
Ohm's law, 369. 
positive elements, 367. 
positive pole, 367. 
static electricity, 367. 
volt, 369. 
Elliott's uterine adjuster, 67. 



Elongation, hypertrophic, of cervix uteri, 

347. 
Encysted dropsy of the peritonaeum, 498, 
Endometritis, 178. 
Enlargement and cysts of the liver, spleen, 

and kidneys, 498. 
Epithelioma, microscopical appearances, 402. 
of the cervix uteri, 401. 
pathology, 401. 
pavement-celled, 401. 
physical signs, 404, 
rodent ulcer, 401. 
secondary invasion, 402. 
symptomatology, 402. 
treatment, 408. 
amputation, 413,. 
astringent injections, 408. 
Baker's operation, 414, 
cannabis Indica, 409. 
caustics, 411, 
chromic acid, 409. 
cocaine, 409. 
constitutional, 408. 
curette, 412. 
diet, 409. 
ecraseur, 413. 
galvano-cautery, 413. 
hydrate of chloral, 409. 
hyoscyamus, 409. 
iodoform, 409. 
local, 408. 
milk of aveloz, 410. 
nitric acid, 409. 

Baquelin's thermo-cautery, 412.' 
rest, 408, 

Schroeder's operation, 413. 
Erosions of cervix uteri, 406, 
Eruptions of vulva, 97. 
diphtheria, 98. 
eczema, 97, 
acute, 97. 
chronic, 97. 
treatment, 97. 
erysipelas, 97. 

treatment, 98. 
gangrene, 98, 
causation, 98, 
prognosis, 98, 
treatment, 98, 
herpes, 97. 
noma, 98. 
prurigo, 97. 



INDEX. 



957 



Eruptions of vulva, prurigo, treatment, 97. 
Erythema, 84. 

Examination of patients, 8, 10. 
anaestliesia, 19. 

method of administration, 19. 
aspirator, 17. 
classification of facts, 4. 
concave mirror, 18. 
curette, 16. ♦ 

Recamier's, 16. 

Skene's, 16. 
dilators, 17. 

Hanks's, 17. 

Palmer's, 17. 
examining table, 8. 
history of reproduction, 7. 
inspection, 3. 

investigation of diseases of sexual sys- 
tem, 5. 
microscope, 18. 
palpation, 10. 
palpation and percussion conjoined, 10. 

diametrical method, 10. 

fluctuation, 10. 

interrupted pressure, 10. 

peripheral method, 10. 
percussion, 10. 
physical signs, 7. 
position, 11. 

dorsal, 8. 

Sims's, 11, 
resume of methods, 19. 
sound and probe, 14. 

elastic, 15. 

Jenks's, 15. 

Simpson's, 14. 

Sims's, 15. 
sound and palpation combined, 16. 
speculum, 11. 

Cusco's bivalve, 11. 

Sims's, 11. 

introduction, 13. 
movements, 13. 
symptomatology, 6. 
tents, 17. 

compressed sponge, 17, 

sea-tangle, 17. 

tupelo, 17. 
touch, 8. 

bimanual, 9. 

by dilatation of urethra, 9. 

rectal, 10. 



Examination touch, single, 8. 

Simon's method, 9. 

vesico-rectal, 10. 

vesico-vaginal, 10. 
Excision of uterus, 415. 
Excrementitious plethora, 431. 
External genital organs, 77. 

Facts, classification of, 4. 
Fallopian tubes, 547. 
anatomy, 547. 
anomalies, 547. 
development, 22, 647. 
diseases, 547. 
Fecal impaction, 498. 
Fibroma of the ovary, 478. 
of uterus, 848. 
synonyms, 348. 
bleeding disease of the uterus (Dun- 
can), 348. 
fibroid, 348. 
fibrous myoma, 348. 
fibro-myoma, 348. 
hysteroma, 348. 
varieties, 349, 

conglomerate, 350. 
interstitial, 349. 
multiple, 350. 
single, 350. 
submucous, 349. 
subperitoneal, 349 
within folds of broad lia'araent, 349. 
calcareous degeneration, 352. 
causation, 359. 
clinical history, 351. 
density, 351. 
diagnosis, 358. 

effects of, upon the uterus, 353, 
fatty transformation, 352. 
osseous degeneration, 352, 
physical signs, 357. 
prognosis, 360. 
symptomatology, 355, 
treatment, 361. 
medicinal, 361. 

ergot, 361. 
surgical, 362. 
curette, 862. 
ecraseur, 362. 
electrolysis, 366. 
hysterectomy, 365. 
Keith's views, 363. 



958 



DISEASES OF WOMEN. 



Fibroma of uterus, surgical treatment, elec- 
trolysis, 366. 

ovariotomy, 365. 
Fibrous polypi, 406. 
Fistula in ano, 162. 
operation, 165. 

Dudley's, 166. 
treatment, 162. 
new method, 166. 
urethral, 904; vesico-vaginal, 892. 
Flexions of the uterus, 54. 
causation, 61. 
diagnosis, 61. 
pathology, 58. 
physical signs, 60. 
symptomatology, 59. 
treatment, 64. 
varieties, 57. 
Fluctuation, 10. 
Foreign bodies in bladder^ 777- 
calculus, 780. 
causation, 781. 
diagnosis, 780. 
prognosis, 781. 
symptomatology, 780. 
treatment, 782. 
in urethra, 875. 
Fossa navicularis, 78. 
Fourchette, 76. 
Fraenulum vulvae, 76. 
Frequent urination associated with slight 

anteversion of bladder, 338. 
Freund's operation for removal of uterus, 

415. 
Functional diseases of bladder, 653. 

derangements of function in which there 
is no recognizable organic lesion, 653, 
causation, 660. 
diagnosis, 659. 
illustrative cases, 663. 
neurosis, 658. 

due to disorders of sexual functions, 

655. 
due to hysteria, 654. 
due to malaria, 656. 
due to ovarian affections, 657. 
prognosis, 659. 
symptomatology, 658. 
treatment, 660. 
derangements of function due to diseases 
of the nutritive and nervous systems, 
674. 



Functional diseases of bladder, paralysis, 674. 

causation, 677. 

diagnosis, 676. 

enuresis nocturna, 680. 

prognosis, 677. 

symptomatology, 675. 

treatment, 677. 
incontinence of urine, 680. 

prognosis, 681. 

treatment, 681. 

illustrative cases, 684. 
derangements of function due to abnor- 
mal condition of urine, 685. 

causation, 687. 

diagnosis, 687. 

illustrative cases, 689. 

prognosis, 687. 

symptomatology, 687. 

treatment, 687. 
derangement of function due to affections 

of the pelvic organs other than the 

bladder, 691. 
Functional diseases of urethra, 818. 
Function of bladder, 647. 
Functions of uterus, 175. 
gestation, 176. 
impregnation, 176. 
menstruation, 30. 

Galvano-cautery, 413. 
Ganglionic dysaesthesia, 429. 
Genital cleft, 82. 

eminence, 82. 
Gestation, ectopic, 920, 
Glands of Xaboth, 174. 
Glandulas vestibulares minores, 78. 

majores, 78. 
Gonorrhoea, 84. 
Goodell's dilator, 17. 
Graduated sounds, 69. 
Granular erosion, 825. 
Gynecology as related to insanity in women, 

930. 

Hasmatosalpinx, 551. 

etiology, 552. 

symptomatology, 552. 

treatment, 552. 
Haemorrhage, arrest of, 527. 
of the bladder, 705. 

causation, 705. 

illustrative cases, 709. 

symptomatology, 705. 



INDEX. 



959 



IIa?raorrhage, arrest of, treatment, 707. 

secondary, 134. 
Haemorrhoid clamp, 151. 
Hawk-bill scissors, 249. 
Ilermaphroditism, 82. 
Hernia of the pudendum, 91. 

anterior labial, 91. 
of the bladder, 769. 

diagnosis, 92. 

posterior labial, 91. 

treatment, 92. 
History of reproduction, 7. 
Hot water in controlling haemorrhage, 134. 
Hunter's depressor, 14. 
Hydatids in the bladder, 779. 
Hydrate of chloral, 409. 
Hydrocele of round ligament, 93. 

treatment, 93. 
Hydronephrosis, 400. 
Hydrosalpinx, 549, 553. 
Hymen, 76, 78, 81. 
Hyoscyamus, 409. 
Hyperaemia of the bladder, 708. 

causation, 704. 

diagnosis, 7041 

symptomatology 704. 

treatment, 705. 
Hyperaesthesia, 109. 
of vulva, 93. 

causation, 94. 

treatment, 94. 
Hyperplasia of bladder, 814. 

diagnosis, 815. 

treatment, 815. 

symptomatology, 815. 
Hypertrophic elongation, 347. 

of the cervix uteri, 124. 
Hypertrophy of the cervix uteri, 343. 

causation, 345. 

pathology, 343. 

physical signs, 344, 

prognosis, 345. 

symptomatology, 343. 

treatment, 345. 
Hypospadias, 82. 
Hysterectomy, 365. 

Keith's cases, 389. 
Hysterotome, Skene's, 74. 
Hysterrorhaphy, 327. 

Hlustrativc cases of abuse of pessariet^ 
334-841. 



] Illustrative cases, bladder: atrophy, 817. 
I cystitis, 752-756. 

derangements, 691. 

dislocations, 762. 

displacements, 771. 

functional diseases, 663-671. 
bladder, foreign bodies in, 783-791. 

irritation of, 689. 

malformations of, 636-646. 

paralysis of, 684. 

prolapsus of, 769. 

rupture of, 797-803. 
cellulitis, pelvic, 564-578. 
coccyx, removal of, 169. 
cervix uteri, cicatrices of, 262-265. 

lacerations of, 252-257. 
endometritis, cervical, 189-200. 

corporeal, 209-212. 
fistulae in ano, 66. 

loss of base of bladder and urethra, 
917-928. 

urethral, 914-916. 

vesico-vaginal, 901-908. 

with stricture of vagina, 911. 
membranous dysmenorrhoea, 237-240. 
menopause, 425-435. 
menstrual derangements caused by ar- 
rested growth of uterus, 41. 

chlorosis, 44-46. 

deranged innervation, 49-53. 

deranged conditions of life, 47. 

malformations of uterus, 32, 38. 

phlegmatic temperament, 50. 
ovarian neoplasms, 530-546. 
pelvic hgematocelc, 603-608. 
pelvir peritonitis, 587-595. 
pelvic floor, atrophy of muscles of, 160. 

injuries of, 149, 159. 

rigidity of muscles of, 161. 
pudendal hajmatocele, 91. 
urethra: dislocation, 864. 

functional diseases of, 819. 

granular erosion, 826. 

gonorrhoeal inflammation, 887. 

organic disease of, 824. 

stricture of, 872. 
urethral glands, gonorrhoeal inflamma- 
tion of, 890. 

tuberculosis of, 889. 
uterus, anteflexion of, 69-73. 

fibroma of, 377-896. 

inversion of, 272, 273. 



960 



DISEASES OF WOMEN. 



Illustrative cases, uterus, retroversion of, 
324-326. 
retroflexion of, 328. 
sclerosis of, 223-228. 
Imperforate vagina, 101. 

hymen, 53. 
Incontinence of rectum, 119. 

of urine, 680. 
Infantile uterus, 23. 
Inflammation of bladder, 703. 
of ovary, 454. 

acute ovaritis, 457. 
causation, 461. 
diagnosis, 460. 
pathology, 458. 
physical signs, 459. 
prognosis, 460. 
symptomatology, 459. 
treatment, 461. 
chronic ovaritis, 461. 
causation, 464. 
pathology, 461. 
physical signs, 464. 
prognosis, 464. 
symptomatology, 4G3. 
treatment, 465. 
hyperaemia, 454. 
causation, 457. 
pathology, 454. 
physical signs, 456. 
prognosis, 457. 
symptomatology, 455. 
treatment, 457. 
of urethra, 821. 
of vagina, 105. 
acute, 105. 
chronic, 105. 
gonorrhoeal, 105. 
erythematous, 105. 
erysipelatous, 105. 
gangrenous, 102. 
of vulvo-vaginal glands, 85. 
physical signs, 85. 
prognosis, 86. 
symptomatology, 85. 
treatment, 86. 
Inflammatory affections of uterus, 176. 
endometritis, 177. 
acute corporeal, 177. 
causation, 178. 
prognosis, 178. 
treatment, 178. 



Inflammatory affections of uterus, chronic, 
178. 
cervical, 179. 
causation, 184. 
cystic degeneration, 181. 
physical signs, 184. 
prognosis, 185. 
pathology, 179. 

symptomatology, 183. 
treatment, 185. 

constitutional, 185. 
local, 186. 
Inguinal labial hernia, 91. 
Injuries of pelvic organs, 334. 
pelvic floor, 112. 
posterior wall of vagina, 337. 
Insanity, gynecology as related to, 930. 
Instruments used in ovariotomy, 519. 
Interrupted pressure, 10. 
Intraligamentous ovarian cystomata, 500, 
532. 
pathology, 501. 
physical signs, 502. 
symptomatology, 502. 
treatment, 504. 
Intra-uterine ligament, 612. 

stem, 69. 
Inversion of uterus, 266. 
causation, 270. 
chronic, 273. 
diagnosis, 269. 
prognosis, 270. 
physical signs, 267. 
symptomatology, 266.' 
treatment, 273. 

methods of reduction, 274. 
Barren, 274. 
Xoeggerath, 274. 
Thomas, 274. 
of bladder, 774. 
Ischio-perineal ligament, 1 14, 
Japanese ligature, 134. 

Knee-chest position, 323. 

Labia majora, 76. 

minora, 76. 
Lacerations, cervix uteri, 242. 

causation, 246. 

consequences, 242. 

frequency, 242. 

importance, 242. 



INDEX. 



961 



Lacerations, cervix uteri, treatment, 248. 
operation, 249. 
varieties, 243. 

antero-posterior, 245. 
incomplete, 245. 
lateral, 243, 245. 
multiple, 245. 
levator-ani muscle, 117-] 22. 
perinaium, 115-118. 
through sphincter-ani muscle, 120. 
Laparo-salpingotomy, 551, 552. 
Laparotomy : 

after-treatment, 528. 
preparatory treatment, 516. 
peritonitis and septicaemia after, 529. 
Lateral displacements of bladder, '764. 
Law battery, 372. 
Leclanche battery, 372. 
Length of vagina, 91. 
Lesions of formation of ovary, 453. 
absent, 453. 
rudimentary, 453. 
supernumerary, 453. 
Levator-ani muscle, causes of injuries to, 

127. 
Ligature, Japanese, 134. 
Loss of the whole base of the bladder and 
urethra, 917. 

illustrative cases, 917. 

Malformations of bladder, 627. 
ana-spadias, 628. 
double bladder, 628. 
diagnosis, 636. 
cpi-spadias, 628. 
etiology, 629. 
eversio vesicae, 628. 
extrophia per urachum, 628. 
extropia vesicse, 628. 
extroversion, 636. 
fissure, 627. 

fistula-vesico-umbilicalis, 627 
inversio vesicae cum prolapsu per fissu- 

ram, 628. 
prognosis, 636. 
treatment, 636. 
of uterus, 25. 
absence, 27. 
at puberty, 25. 
during embryonic life, 25. 
illustrative cases, 28. 
uterus bipartis, 26. 



Malformations of uterus, bicornis, 26. 

bifundalis unicollis, 26. 

duplex, 26, 

hypertrophy, 25. 

rudimentary, 27, 30. 

unicornis, 26. 
of urethra, 622. 

atresia urethrae, 623. 
defectus urethrae totalis, 622. 
defectus urethrae extei'nus, 622. 
defectus urethrae internus, 623. 
diagnosis, 625. 
double urethra, 624. 
hypospadias, 623. 
symptomatology, 624. 
treatment, 626. 
of vagina, 100. 
atresia, 101. 

acquired, 101. 

causation, 103. 

complete, 101. 

congenital, 101. 

illustrative cases, lOL 

partial, 101. 

physical signs, 102. 

symptomatology, 102. 

treatment, 103. 

Dupuytren's operation, 103. 

Porteau's trocar, 105. 

Sims's dilator, 104. 
double vagina, 100. 
imperforate hymen, ino. 
imperforate vagina, 101. 
perpetuation of septum, 100. 
prognosis, 103. 
Malignant disease of uterus, 398. 
cancer, 398. 

cancer of cervix uteri, 398. 
cancer-juice, 399. 
colloid, 400. 
encephaloid, 399. 
epithelioma, 399, 
melanotic, 399. 
pathology, 399. 
pathological effects, 400. 

h3'dronephrosis, 400. 

rectitis, 400. 

vesi CO- vaginal fistulae, 400. 
scirrhus, 309. 
definition, 398. 
sarcoma, 398. 
Massage of uterus, 216, 326, 



962 



DISEASES OF WOMEN". 



Mature uterus, 24. 

Meatus urinarius, 78. 

Median laceration of perinaeum down to 

sphincter ani, 145. 
Medullary cancer, 405. 
Membranous dysmenorrhoea, 229. 
causation, 233. 
illustrative cases, 237. 
membrane of, 232. 
pathology, 229. 
physical signs, 232. 
symptomatology, 231. 
treatment, 235. 

Barker's, Dr. Fordyce, case, 240. 
Menopause, 422. 

illustrative cases, 425. 
natural history of, 422. 
symptomatology, 423, 
treatment, 424. 
Menstruation, 30. 

composition of menstrual flow, 31. 
derangement from arrest of development, 
30. 

illustrative cases, 32. 
derangement from causes independent of 
sexual organs, 46. 
illustrative cases, 49. 
laws of, 31. 
premature, from deranged condition of 

life and delayed innervation, 47. 
methods of observation, 1. 
Methods of exploration of bladder and 
urethra, 694. 
cystoscope, 697. 
dilatation of urethra, 699. 
examination of urine, 694. 
incision into the bladder, 701. 
list of instruments, 702. 
Napier's probe, 699. 
Simon's method, 699. 
Skene's bivalve urethral speculum, 700, 
Skene's endoscope, 695. 
touch, 694. 

applying electric current, 375. 
Metritis, 176. 
acute, 176. 
chronic, 176. 
Microscopic contents of ovarian cysts, 481. 
Microscope in diagnosis, 18, 
Milliamperemeter, 374, 
Milk of aveloz, 410. 
Minute anatomy of ovary, 443. 



Mirror, concave, 18. 
Mons veneris, 76. 
Mucous membrane, 173. 

glands, 78. 
Miiller's ducts, 22, 

filaments, 22. 
Multilocular cyst, 474. 
Myoma, 110. 

Naboth, glands of, 174. 
Needles, Emmet's, 898. 
Keith's, 520. 
Peaslee's, 129. 
Skene's, 250. 
Needle forceps, 141, 250. 
Neoplasms of bladder, 804. 
benign, 804. 
fibroma, 804. 
myo-fibroma, 804. 
myoma, 804. 
myxoma, 804. 
tubercle, 811. 
malignant, 804. 
encephaloid, 804. 
epithelioma, 804, 812. 
sarcoma, 804. 
scirrhus, 804. 
causation, 809. 
diagnosis, 808. 
pathology, 804. 
symptomatology, 806. 
treatment, 809. 
of Fallopian tubes, 548. 
carcinoma, 548. 
cystoma, 548. 
fibroma, 548. 
lipoma, 548. 
Morgagni's hydatid, 548. 
myoma, 548. 
papilloma, 548. 
sarcoma, 548. 
tubercle, 548. 
of ovary, 473. 

adenoid cystoma, 473. 
carcinoma, 473. 
cystic tumors, 473. 
cysto-carcinoma, 473. 
fibroma, 473. 
sarcoma, 473. 
dermoid cystoma, 473. 
follicular cyst, 473. 
fibrous cyst, 473. 



INDEX. 



963 



Neoplasms of ovary, multiple cystoma, 473. 

multilocular cystoma, 4*73. 

multiple follicular cystoma, 473 

papillary cystoma, 476. 

sarcoma, 473. 

simple follicular cystoma, 473. 

simple unilocular cystoma, 473. 
of urethra, 835. 

areolar, 837. 

compound, 838. 

epithelial, 838. 

glandular, 836. 

papillary, 836. 

vascular, 837. 
of vagina, 109. 

carcinoma, 111. 

cysts, 109. 

fibroma, 110. 

fibromyoma, 110, 

myoma, 1 10. 

sarcoma. 111. 
Neurosis, 654. 

Nitrate of silver, long-continued use of, 193. 
Normal menopause, 425, 
NymphsB, 76. 

Observation, method of, 1. 
Oophorectomy, 509. 
Orificium vaginae, 80. 
Ovarian cysts, 474. 
classification, 473. 
complex cystoma, 477. 
compound cysts, 475, 
complications, 483. 
cystitis, 486. 
dragging of pedicle, 485, 
perforation, 486. 
rupture of cyst, 485, 
contents of cysts, 481. 
cyst-wall, 480. 
cysto-fibroma, 479. 
dermoid cysts, 478. 
diagnosis, 491, 493. 
ascites, 499. 

cyst of broad ligament, 499. 
distended bladder, 498. 
encysted dropsy of peritonaeum, 498. 
enlargement and cysts of liver, spleen, 

and kidneys, 498. 
parovarian cyst, 499. 
uterine fibroids and fibrO' cysts, 497, 
500. 



Ovarian cysts : fibroma of ovary, 479. 
glandular cell of Drysdale, 483. 
intraligamentous, 500. 
multilocular cysts, 476. 
microscopic contents, 482. 
ovarian granular cell (Drysdale), 483. 
papillary cysts, 478. 
pathology, 474. 
physical signs, 490. 
simple cysts, 475. 
symptomatology, 488. 
treatment, 509. 

ovariotomy, 509. 
Ovarian neoplasms, 473. 

hyperaemia, 454, 
Ovaries, anatomy of, 438. 
displacements, 467*. 
prolapsus, 454. 
Ovario-uterine neuralgia, 434. 
Ovariotomy, 509. 
after- treatment, 528. 
antisepsis, 514. 
arrest of haemorrhage, 527. 
assistants, 521. 

duties of, 521. 

positions of, 521. 
complications, 524. 
drainage, 526. 

emptying cysts in complicated cases, 525. 
general considerations, 510. 
illustrative ca?es, 530, 543. 
immediate preparation of patient, 518. 
Keith's, cases, 543. 

list of instruments and appliances usually 
needed, 519*. 

fenestrated forceps, 519. 

Keith's clamp, 520. 

Keith's compression-forceps, 519*. 

Keith's ligature-forceps, 520. 

Keith's needles, 520. 

vulcellum forceps, 519. 
list of instruments that may be needed, 
520. 

cautery clamp, f 20. 

cautery irons, 520. 

counter-pressure instrument, 520. 

drainage-tubes, 520. 
operating-table, 518. 
pedicle, management of, 515. 
removal of uterine appendages, 509. 
steps of operation, 522, 

cleansing abdominal cavity, 522. 



964: 



DISEASES OF WOMEN. 



Ovariotomy, steps of operation : 

closing abdominal wall, 522. 

dressing abdominal wound, 522. 

examining other ovary, 522. 

exploring for adhesions, 522. 

making incision in abdominal wall, 522. 

placing patient in bed, 522. 

removing tumor, 522. 

tapping cyst, 522. 

treating adhesions, 522. 

treating pedicle, 523. 

treatment of suppurating cysts, 622. 
Ovaritis, acute, 454, 457. 

chronic, 454. 
Ovulation, 446. 

Palma plicata, 23. 

Palpation and percussion conjoined, 10, 20. 
Papillary cysts, 476. 
Paquelin's cautery, 111. 
Paralysis of bladder, 674. 
Parovarian cysts, 499. 
Patient, position of, 11. 
Pavement-celled epithelioma, 401. 
Pelvic cellulitis, 555. 
causation, 558. 
illustrative cases, 569. 
pathology, 556. 
physical signs, 561. 
symptomatology, 560. 
treatment, 562. 
Pelvic floor: anatomy, 112. 

bulbo-cavernosus muscle, 113. 
coccygeus, 113. 
injuries, 112. 
levator-ani muscle, 112. 
transversus periuaei muscle, 112. 
sagging of, 123. 
sphincter-ani muscle, 114. 
haematocele, 596. 
causation, 599. 
illustrative cases, 603. 
intra-peritoneal, 597. 
pathology, 597. 
physical signs, 600. 
subperitoneal, 597. 
sjrmptomatology, 599. 
treatment, 601. 
peritonitis, 579. 
causation, 582. 
illustrative cases, 587. 
pathology, 580. 



Pelvic floor, peritonitis : 
symptomatology, 583. 
treatment, 584. 
Percussion, 10. 
PerinEeum, 112. 
anatomy, 112. 

ischio-perineal ligament, 114. 
bulbo-cavernosus muscle, 113. 
levator-ani muscle, 112. 
sphincter-ani muscle, 114. 
transversus-perina?i muscle, 112. 
functions, 114. 
injuries, 115. 
causation, 126. 
diagnosis, 124. 
illustrative cases, 144. 
symptomatology, 125. 
Perineorrhaphy, 1 2S. 
primary operation, 128. 

general considerations, 128. 
Peaslee's needle, 129. 
silk sutures, 129, 135. 
silver wire, 129, 135. 
catheter, 137. 
conditions necessary for healing of 

wounds, 131. 
conditions unfavorable for healing ot 

wounds, 132. 
description of operation for rupture in 
first degree, 137. 
denundation, 137. 
instruments, 138. 
introduction of sutures, 140. 
method, 138. 
dressings, 136. 

description of operation for the restora- 
tion of sphincter-ani muscle and peri- 
nseum, 147. 
denudation, 147. 
introduction of sutures, 148. 
illustrative cases, 149. 
description of operation for restoration 
of pelvic floor in subcutaneous lacer- 
ation between the vagina and rec- 
tum, 155. 
denudation, 155. 
introduction of sutures, 155. 
Peri-salpingitis, 548. 
Pessaries, abuse of, 334. 
adaptation of, 317. 
Albert Smith's, 317. 
cup, badly adjusted, 3 39, 



INDEX. 



965 



Pessaries : 
Cutter's, 300. 
glass globe. 298. 
lever action of, 321, 322. 
Peaslee's, 297. 

stem injuring cervix uteri, 334. 
injuring body of uterus, 336. 
Skene's, for prolapsus of bladder, 667. 
Physical signs of disease, 7. 
Physiology of ovary, 438. 
Premature menopause, 427. 
Preparation of silk sutures, 140 
Preputium, 77. 
Probe, uterine, 14. 
Probing, uterus, 16. 
Process of vivifying tissues, 147. 
Prolapsus of mucous membrane of rectum, 
120. 

of ovary, 468. 
causation, 471. 
physical signs, 470. 
prognosis, 470. 
symptomatology, 469. 
treatment, 471. 
or inversion of the urethral mucous mem- 
brane, 866. 
result of degeneration of supports of 

uterus, 289. 
uteri, 287. 

first degree, 287. 
second degree, 287. 
third degree, 287. 
treatment, 295. 
Protection of perineal wound, 136. 
Pruritis of vulva, 94. 
pathology, 94. 
physical signs, 94. 
symptomatology, 94. 
treatment, 95. 
Pscudo-hermaphroditism, 82. 
Pudendal haematocele, 89. 
causation, 90. 
diagnosis, 90. 
illustrative cases, 91, 
physical signs, 89. 
symptomatology, 89. 
treatment, 90. 
Pudendum, 76. 
anatomy, 76. 
development, 81. 
diseases, 84, 
Pyosalpinx, 548, 554. 



Kectitis, 400. 
Rectum, 82. 

digital touch by, 10. 

examination of pelvic organs through, 9, 
Recurrent fibroids, 419. 
Removal of uterine appendages, 509. 
of coccyx, 170. 
of sutures, 145. 
Repositors : 

Aveling's. 

Byrne's. 

De Paul's. 

White's. 
Reproduction, history of, 7. 
Results of surgical treatment of laceration 

of cervix uteri, 258. 
Retroflexion of the uterus, 328. 

causation, 330. 

degrees, 328, 

pathology, 328. 

physical signs, 329. 

prognosis, 330. 

symptomatology, 328. 

treatment, 331. 
Retroversion of uterus, 304. 

treated by pessaries, 312. 
Rheostat, 374. 
Rigid perinseum, 125, 

Rigidity of muscles of pelvic floor from in- 
flammatory sclerosis, 161. 
Round ligaments, 282. 
Rudimentary uterus, 35. 
Rupture of bladder, 793. 

causation, 796. 

complete, 793. 

incomplete, 793. 

patholog}^ 793. 

prognosis, 795, 

symptomatology, 794. 

treatment, 796. 
and perforation of ovarian cysts, 485. 

Sagging of the pelvic floor, 123. 
Salpingitis, 548. 

acute, 548. 

causation, 550. 

chronic, 548. 

illustrative cases, 553. 

pathology, 548. 

physical signs, 549. 

prognosis, 550. 

symptomatology, 549. 



966 



DISEASES OF WOMEi^. 



Salpingitis : treatment, 550. 
Sarcoma of uterus, 419. 

causation, 419. 

diagnosis, 419, 

fibroplastic tumors, 419. 

pathology, 419. 

prognosis, 419. 

physical signs, 419. 

recurrent fibroids, 419. 

symptomatology, 419. 

treatment, 419. 
Scar in vaginal wall from labor, 263. 
Scar tissue, 120. 

producing stenosis of vagina, 262. 
caused by forceps, 265. 
■ by treatment, 264. 
Scirrhus, 399. 
Scissors for removing sutures, 145. 

hawk-bill, 249. 
Sclerosis of uterus, 220. 

causation, 222. 

illustrative cases, 223. 

pathology, 220. 

prognosis, 222. 

physical signs, 222. 

symptomatology, 221. 

treatment, 223. 
of cervix uteri, 223. 

following puerperal metritis, 224. 

resulting from endometritis and gen- 
eral congestion, 226. 
Sebaceous glands, 78. 
Secondary haemorrhage, 134. 
Septum, perpetuation of, 100. 
Sexual organs, development of, 22. 
Silk sutures, preparation of, 140. 
Silver wire, 129. 
Simon's method, 9. 

scoop, 412. 
Simple cyst, 474. 
Sims's vaginal dilator, 105. 

sponge-holder, 898. 
Skene's glands, 614. 

hysterotome, 74. 
Soft fibroma, 387. 
Sounds, uterine, 14. 

Jenks's, 14. 

Sims's, 14. 
Spasmodic muscular contraction, 1 25. 
Speculum: Cusco's, 11. 

movements of, 13. 

Sims's, 11. 



Sphincter vagina?, 121. 
Sponge-holders : Sims's, 898. 
Stricture : at junction of urethra and blad- 
der, 870. 
of urethra, 868. 
Subcutaneous separation of muscles of pel- 
vic floor, 117. 
Subinvolution of uterus after parturition, 
214, 217. 

causation, 215. 

illustrative cases, 217. 

pathology, 215. 

physical signs, 215. 

prognosis, 215. 

symptomatology, 215. 

treatment, 216;. 
Superinvolution of uterus, 217. 
Supernumerary ovaries, 453. 
Suppurating ovarian cysts, 543. 
Sutures, 135. 

braided silk, 135. 

catgut, 135. 

introduction of, 898. 

prepared silk, 135. 

silver wire, 135. 

twisted silk, 135. 

tying of, 898. 
Syphilitic ulcerations, 406. 
Syphilis, 84. 
Systems, 5. 

muscular, 5. 

nervous, 5. 

nutritive, 5. 

sexual; 5. 

Taxis, 274. 

Tenaculum, Sims's, 898. 
Tents : 

compressed sponge, 17. 

sea-tangle, 17. 

tupelo, 17. 
Tissue forceps, 138. 
Torsion, 134. 
Touch, examination by, 8. 
Tubercle of bladder, 811. 
of Fallopian tubes, 551. 
Tubes, Fallopian, 22. 
Tubo-ovariotomy, 509. 

Uncomplicated vulvitis, 84. 

Unilateral laceration, 285. 

Ureters, diseases and injuries of, 909. 



mDEX. 



967 



Ureters, catheterization of, 910. 

illustrative cases, 913, 919. 
Urethra, 82. 

anatomy of, 613. 

development, 609. 

digital dilatation, 9. 

fistula, 904. 
Urinary organs, diseases of, 609. 
Uro-genital sinus, 82. 
Use of catheter, 137. 
Uterus, 30. 

absence of, 25. 

at puberty, 25. 

bicornis, 25. 

bifundalis unlcollis, 25. 

bipartis, 25. 

bleeding disease of, 356, 

development of, 22. 

dislocations of, 279. 

displacements of, 286. 
anteversion, 286. 
prolapsus, 286. 
retroversion, 286. 
restoration, 295. 

double, 28, 29. 

duplex, 25. 

excision of, 415. 

functions of, 175. 

hypertrophy of, 30. 

infantile, 23. 

malformation of, 25. 

massage of, 216, 326. 

mature, 24. 

middle or muscular walls of, 175. 

probing of, 16. 

retroversion of, 328. 

rudimentary, 25. 

unicornis, 25. 
Uterine appendages, 509. 

dilator, 17, 69. 

electrode, 376. 

fibro-cysts, 500. 

fibroids, 497. 

pregnancy, 359. 

probe, 14. 

sound, 14. 

Vagina: cysts of, 109. 

development, 22. 

double, 28. 
Vaginal dilator, Sims's, 105. 
enterocele, 92. 



Vaginal enterocele, causation, 92. 
diagnosis, 92. 
treatment, 93. 
Vaginismus, 109. 
Vaginitis, 105. 
acute, 105. 
catarrhal, 106. 
causation, 107. 
chronic, 105. 
diphtheritic, 105. 
erysipelatous, 105. 
erythematous, 105. 
exudative, 106. 
gonorrhoeal, 105. 
idiopathic, 105. 
pathology, 105. 
physical signs, 107. 
prognosis, 107. 
purulent, 106. 
secondary, 105. 
subacute, 106. 
symptomatology, 106. 
treatment, 107. 
Varicose veins of vulva, 87. 
causation, 87. 
physical signs, 87. 
symptomatology, 87. 
treatment, 87. 
Vesical and urethral fistulse, 892. 
causation, 894. 
classification, 892. 
urethro-vaginal, 892. 
utero-vaginal, 892. 
vesico-vaginal, 892. 
complications, 894. 
illustrative cases, 901. 
physical signs, 893. 
prognosis, 8^4. 
symptomatology, 893. 
treatment, 895, 

after-treatment, 901. 
operation, 896. 

Emmet's needles, 899. 
introduction of sutures, 898. 
paring the edges of fistula, 897. 
Sims's sponge-holder, 898. 
Sirns's tenaculum, 897. 
preparatory treatment of, 895. 
Vesico-rectal examination, 20. 

touch, 20. 
Vesico-urethral fissure, 829. 
Vesico-utcrine fistula, 906. 



968 



DISEASES OF WOMEN. 



Yesico-vaginal examination, 10. 
fistula, 400, 896, 901. 

complicated, 902. 
touch, 20. 
Vestibule, 77, 82. 
Virgin uterus, 24. 
Vulva, complete atresia of, 82. 
Vulvitis, 84. 

causation, 84. 

diagnosis, 85. 

due to cancer of uterus, 84. 

due to vaginitis, 84. 

erythematous, 84. 

follicular, 84. 

gonorrhoea], 84. 



Vulvitis, physical signs, 85. 
primary, 84. 
purulent, 84. 
secondary, 84. 
s}-philitic, 84. 
symptomatology, 85. 
treatment, 85. 

Water, ice, or cold, use of, 134. 
Wounds of pudendum, 87. 
contused, 89. 

incised and punctured, 85. 
causation, 85. 
symptomatology, 85. 
treatment, 85. 



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